___________________________________________
Nationally Endorsed Process Measures
Specifications
LFG2006 indicates following items taken from current LFG process specs, for consideration this year.
Introduction
The specifications in this document are for auditing and measuring the rate of adherence to process
measures of quality. Because of the clinical specificity needed, procedure and condition definitions
DIFFER from those used to count volume of procedures elsewhere in the survey and should not be used
for that purpose.
Every effort has been made to harmonize these process measures with national performance
measurement systems such as JCAHO, CMS, Vermont Oxford Network (VON) or National Quality Forum
(NQF) Endorsed Measure Sets, to reduce the reporting burden on survey respondents. The measure
identifies if the specifications are from a national measure set or a NQF endorsed measure set. If the
measure is from a national performance measurement system (such as STS, ACC, ACS) data reported to
those organizations consistent with their specifications can and should be used to report hospital
performance for these indicators in the Leapfrog Survey. In some cases, measures used for another
diagnosis are adapted to a procedure associated with that diagnosis (e.g., PCI and AMI—there were no
“identified” measure sets that were attached to the procedure PCI; but there were measure sets (JCAHOAMI) that measured PCI within that diagnostic group (AMI).
General Instructions
1. If your hospital has
 measured adherence to the process-of-care quality indicator,
 reported the results to JCAHO, CMS or VON
 for a one-year period ending not more than 12 months prior to survey submission.
Use data as reported for that measure in responding to the survey. To the extent any specifications
below differ from the specifications for reporting the data to those organizations, rely on the
specifications of that organization.
2. For those indicators not measured and reported to JCAHO, CMS or VON for a recent period (i.e., a
one-year period ending not more than 12 months prior to survey submission), you should measure
adherence to the process-of-care quality indicator and use those results in responding to the survey.
See also the Frequently Asked Questions at the end related to measuring these indicators.
3. In either case #1 or #2, we ask that you report the number of cases in the denominator and that you
report the number of cases where there was adherence to the measurement standard (numerator).
Note: in order to attain credit you will need to have 80% or more adherence to a minimum of two
process measures within the procedure you are submitting, except in the case of high risk delivery,
where there is only one process measure included in the survey.
Links throughout this document to JCAHO Appendices and measures can be located at
www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm
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Nationally Endorsed Process Measures
Specifications
Measurement Guidelines for Coronary Artery Bypass Graft (CABG) Indicators
CABG-1: Anti-platelet medication at discharge
Source: STS NQF Endorsed
Numerator: Number of patients who were discharged on aspirin/safety-coated aspirin or clopidogrel
after isolated CABG.
Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.15
Single internal mammnary-coronary bypass
36.16
Souble internal mammary-coronary bypass
36.19
Other bypass anastamosis for heart revascularization
Exclusions: per JCAHO-CMS
 <18 years of age
 Transferred to another acute care hospital
 Expired
 Left against medical advice
 Discharged to hospice
 One or more of the following aspirin contraindications/reasons for not prescribing aspirin
documented in the medical record:
o Aspirin allergy
o Active bleeding on arrival or during hospital stay
o Warfarin/Coumadin prescribed at discharge, or
o Other reasons documented by physician, nurse practitioner, or physician assistant for
not prescribing at discharge
CABG-2: Isolated CABG using internal mammary artery
Source: CMS-NQF Endorsed
Numerator: Number of isolated CABG patients who received an IMA graft
ICD9 procedure codes 36.15 and 36.16
Denominator: Number of surgical patients with isolated CABG ICD-9-CM procedure codes:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.15
Single internal mammnary-coronary bypass
36.16
Souble internal mammary-coronary bypass
36.19
Other bypass anastamosis for heart revascularization
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Nationally Endorsed Process Measures
Specifications
Exclusions:
 Other heart procedures (ICD-9 procedure codes 37.32; 37.34; 37.35; 36.2; 35.0-35.99)
 Repeat CABG (ICD-9 status code V45.81)
 Patient <20
LFG2006:
Exclusion criteria1,2 for IMA grafting = Documentation of one or more of the following
 The Left Anterior Descending (LAD) artery is not suitable for LIMA grafting (eg,
donor or target vessels <1.5 mm in size)
 Calcified or diffuse coronary disease in the LAD
 Subclavian stenosis
 Previous thoracic surgery
 Previous radiation
 Current use of immunosuppressive agents (eg, Prednisone, Imuran, or other)
 Coagulation disorder
 Myocardial infarction within 7 days prior to the procedure
 Chronic renal insufficiency
 Require emergent operation
 Require concomitant surgery (eg. aneurysm resection, valve replacement)
 Morbid obesity
 Other reasons as documented by physician, nurse practitioner, or physician
assistant
CABG-3: Pre-operative beta blockade for isolated CABG surgery
LFG2006: Beta-blocker within 24 hours after surgery
Source: STS-NQF endorsed
Numerator: Number of patients coming to isolated CABG with documented pre-operative (24 hours)
beta blockade
Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.15
Single internal mammnary-coronary bypass
36.16
Souble internal mammary-coronary bypass
36.19
Other bypass anastamosis for heart revascularization
1
Sethi GK, Copeland JG, Moritz T, Henderson W, Zadina K, Goldman S. Comparison of postoperative complications
between saphenous vein and IMA grafts to left anterior descending coronary artery. Ann Thorac Surg 1991;
51: 733-738.
2 Berger PB, Alderman EL, Nadel A, Schaff HV. Frequency of early occlusion and stenosis in a left internal mammary
artery to left anterior descending artery bypass graft after surgery through a median sternotomy on conventional
bypass: benchmark for minimally invasive direct coronary artery bypass. Circulation 1999; 100: 2353-2358.
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Nationally Endorsed Process Measures
Specifications
Exclusions: Patient <20
LFG2006:
Contraindications to beta-blockers (as per JCAHO for beta-blockers in AMI) =
Documentation of one or more of the following [NOTE: Patients having one or more of the following
contraindications may still potentially be eligible to receive the medication.]
 Allergy to beta-blockers
 Bradycardia (heart rate < 60 beats/min) on day of discharge or the previous day, while
not on a beta-blocker
 Systolic blood pressure < 90 mm Hg on day of discharge or the previous day, while not
on a beta-blocker
 Second- or third-degree AV heart block at any time during hospitalization or on
admission, if no pacemaker
 Other reasons as documented by physician, nurse practitioner, or physician assistant
LFG2006:
Definitions:
Beta-blockers = oral beta-blockers as specified by JCAHO beta-blockers in AMI (Appendix C: Medication
Tables)
CABG-4: Beta-blockers prescribed at discharge
Source: STS-NQF endorsed
Numerator: Number of isolated CABG patients discharged on beta blockers
Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.15
Single internal mammnary-coronary bypass
36.16
Souble internal mammary-coronary bypass
36.19
Other bypass anastamosis for heart revascularization
Exclusions: Patient <20
LFG2006:
Contraindications to beta-blockers (as per JCAHO for beta-blockers in AMI) =
Documentation of one or more of the following [NOTE: Patients having one or more of the following
contraindications may still potentially be eligible to receive the medication.]
 Allergy to beta-blockers
 Bradycardia (heart rate < 60 beats/min) on day of discharge or the previous day, while
not on a beta-blocker
 Systolic blood pressure < 90 mm Hg on day of discharge or the previous day, while not
on a beta-blocker
 Second- or third-degree AV heart block at any time during hospitalization or on
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Specifications

admission, if no pacemaker
Other reasons as documented by physician, nurse practitioner, or physician assistant
LFG2006:
Definitions:
Beta-blockers = oral beta-blockers as specified by JCAHO beta-blockers in AMI (Appendix C:
Medication Tables)
CABG-5: Lipid-lowering regimen prescribed at discharge
Source: STS-NQF endorsed
Numerator: Number of isolated CABG patients discharged on a statin or other pharmacologic lipidlowering regimen
Denominator: Total number of surgical patients with CABG ICD-9-CM procedure codes:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.15
Single internal mammnary-coronary bypass
36.16
Souble internal mammary-coronary bypass
36.19
Other bypass anastamosis for heart revascularization
LFG2006:
1. An LDL level > 100 mg/dL as determined by lipid profile test before the surgery
Exclusions: Patient <20
LFG2006:
Contraindications to lipid-lowering agents3,4 = Documentation of one or more of the following [NOTE:
Patients having one or more of the following contraindications may still potentially be eligible to receive
the medication.]
 Allergy to any of the lipid lowering products mentioned in # 3
 Complete biliary obstruction
 Preexisting gallbladder disease
 Active liver disease
 Unexplained persistent elevated liver function tests
 Severe renal dysfunction
 Severe biliary cirrhosis
3
The Post Coronary Artery Bypass Graft Trial Investigators (Post- CABG). The effect of aggressive lowering of low
density lipoprotein cholesterol levels and low dose anticoagulation on obstructive changes in saphenous vein
coronary bypass grafts. N Engl J Med 1997; 336: 153-162.
4
Pitt B, Waters D, Brown WV, van Boven AJ, Schwartz L, Title LM, Eisenberg D, Shurzinske L, McCormick LS.
Aggressive lipid- lowering therapy compared with angioplasty in stable coronary artery disease (AVERT). N Engl J
Med 1999; 341: 70-76.
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Nationally Endorsed Process Measures
Specifications

Other reasons as documented by physician, nurse practitioner, or physician assistant
LFG2006:
Definitions:
Lipid-lowering agents = (Lovastatin, Simvastatin, Pravastatin, Fluvastatin, Atorvastatin, Cerivastatin,
Colestipol, Cholestyramine, Colesevelam, Gemfibrozil, Fenofibrate, Nicotinic Acid, (Clofibrate,
Dextrothyroxine – these two agents are not commonly used as antihyperlipidemics) and Zetia® 2
(ezetimibe)
CABG-6: Prophylactic antibiotic selection for surgical patients -- isolated CABG
Source: JCAHO-CMS (SCIP-Inf-2b); see JCAHO specifications manual
Numerator: Number of isolated CABG surgery patients who received prophylactic antibiotics
recommended for CABG surgery: cefazolin, cefuroxime, cefarnandole, or vancomycin* (see approved
list JCAHO) need JCAHO link or reference
Denominator: Total number of surgical patients with CABG ICD-9-CM procedure codes:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.15
Single internal mammnary-coronary bypass
36.16
Souble internal mammary-coronary bypass
36.19
Other bypass anastamosis for heart revascularization
Exclusions:
 Patients who had a principal or admission diagnosis suggestive of preoperative infectious diseases
(from Appendix A, Table 5.09 for ICD-9-CM codes) need JCAHO link or reference
Principal or admission diagnosis really? suggestive of pre-operative infectious disease:
o Infectious diseases 001.0-139.8
o Meningitis 320.0-326
o Ear Infection 380.0-380.23; 382.0-382.20
o Endocarditis 421.0-422.99
o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1
o Digestive 540-542; 575.0
o Renal 590-590.9; 595.0
o Prostate 601.0-601.9
o Gynecologic 614-614.9 ; 616-616.4
o Skin 680-686.9
o Musculo-skeletal 711.9-711.99; 730.0-730.99
o Fever of unknown origin 780.6
o Septic Shock 785.59
o Bacteremia 790.7
o Viremia 790.8
OR
 Patients who were receiving antibiotics within 24 hours prior to arrival (except colon surgery
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Specifications




patients taking oral prophylactic antibiotics)
Patients who were receiving antibiotics more than 24 hours prior to surgery (except colon surgery
patients taking oral prophylactic antibiotics)
Patients less than 18 years of age
Patients with physician documented infection prior to surgical procedure of interest
Patients whose procedure of interest occurred prior to date of admission
* Special consideration: For cardiac and vascular surgery, if patient is allergic to b-lactarn, then
vancomycin or clindarnycin is an acceptable substitute but vancomycin on list, always acceptable?
CABG-7: Prophylactic antibiotic received within 1 hour prior to surgical incision -- CABG
Source: JCAHO-CMS; NQF-Endorsed (SCIP-Inf-1b); see JCAHO specifications manual
Numerator: Number of isolated CABG surgical patients who received prophylactic antibiotics within
one hour of surgical incision (two hours if receiving vancomycin or fluouroqinolone).
Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.15
Single internal mammnary-coronary bypass
36.16
Souble internal mammary-coronary bypass
36.19
Other bypass anastamosis for heart revascularization
Exclusions:
 Principal or admission diagnosis really? suggestive of pre-operative infectious disease:
o Infectious diseases 001.0-139.8
o Meningitis 320.0-326
o Ear Infection 380.0-380.23; 382.0-382.20
o Endocarditis 421.0-422.99
o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1
o Digestive 540-542; 575.0
o Renal 590-590.9; 595.0
o Prostate 601.0-601.9
o Gynecologic 614-614.9 ; 616-616.4
o Skin 680-686.9
o Musculo-skeletal 711.9-711.99; 730.0-730.99
o Fever of unknown origin 780.6
o Septic Shock 785.59
o Bacteremia 790.7
o Viremia 790.8
OR
 Patients who were receiving antibiotics at time of admission
 Medical records do not include antibiotic start date/time or incision date/time
 Patients receiving antibiotics more than 24 hours prior to surgery
 Age?
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Nationally Endorsed Process Measures
Specifications
CABG-8: Prophylactic antibiotics discontinued within 24 hours after surgery end -- CABG
Source: JCAHO-CMS (SCIP-Inf-3b); see JCAHO specifications manual
Numerator: Number of isolated CABG patients who received prophylactic antibiotics within 24 hours
after surgery end time.
Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes below:
36.10
Aortocoronary bypass for heart revascularization, NOS
36.11
Aortocoronary bypass for one coronary artery
36.12
Aortocoronary bypass for two coronary arteries
36.13
Aortocoronary bypass for three coronary arteries
36.15
Single internal mammnary-coronary bypass
36.16
Souble internal mammary-coronary bypass
36.19
Other bypass anastamosis for heart revascularization
Exclusions:
 Principal or admission diagnosis really? suggestive of pre-operative infectious disease:
o Infectious diseases 001.0-139.8
o Meningitis 320.0-326
o Ear Infection 380.0-380.23; 382.0-382.20
o Endocarditis 421.0-422.99
o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1
o Digestive 540-542; 575.0
o Renal 590-590.9; 595.0
o Prostate 601.0-601.9
o Gynecologic 614-614.9 ; 616-616.4
o Skin 680-686.9
o Musculo-skeletal 711.9-711.99; 730.0-730.99
o Fever of unknown origin 780.6
o Septic Shock 785.59
o Bacteremia 790.7
o Viremia 790.8
OR
 Patients who were receiving antibiotics at time of admission
 Medical records do not include antibiotic start date/time or incision date/time
 Patients receiving antibiotics more than 24 hours prior to surgery
 No antibiotics received before or during surgery, or within 24 hours after surgery end-time (i.e., the
patient did not receive antibiotics)
 Diagnosed with and treated for infections within two days after surgery date
 No antibiotics received during the hospitalization
 Age?
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Specifications
Measurement Guidelines for Percutaneous Coronary Intervention (PCI)
PCI-1: PCI received within 90 minutes of hospitalization
Source: JCAHO (AMI-8a)
Numerator: AMI patients whose time from hospital arrival to PCI is 90 minutes or less.
Denominator: Total number of AMI patients who have undergone PCI
Principal discharge diagnosis of AMI determined using the following ICD-9 diagnsosis codes for AMI
(Appendix A: AMI Codes from JCAHO website):
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.61
True posterior wall, acute myocardial infarction-initial episode
410.71
Subendocardial, acute myocardial infarction
410.81
Other specified sites, acute myocardial infarction-initial episode
410.91
Unspecified site, acute myocardial infarction-initial episode
And
PCI determined using the following ICD-9 procedure codes as principal or secondary procedure:
00.66
Percutaneous transluminal coronary angioplasty [PTCA] or
coronary atherectomy (code effective 10/1/2005)
36.01
Single vessel percutaneous transluminal coronary angioplasty
without mention of thrombolytics (code discontinued 10/1/2005)
36.02
Single vessel percutaneous transluminal coronary angioplasty with
mention of thrombolytics (code discontinued 10/1/2005)
36.05
Multiple vessel PTCA at the same session with or without mention
of thrombolytics (code discontinued 10/1/2005)
36.06
Insertion of coronary artery stents
Insertion of drug-eluting coronary artery stent(s)
36.07
LFG2006:
Eligible = Patients with acute myocardial infarction (AMI) and
 ST-segment elevation or
 new or presumed new left bundle branch block5
Exclusions: (As per JCAHO for aspirin in AMI)
 Age < 20 years
 Transferred to another acute care hospital
 Expired during hospitalization
5
Upon review with comparable JCAHO measure AMI-8a, we are consistent in our definition of patient eligibility.
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Nationally Endorsed Process Measures
Specifications
 Left against medical advice
 Discharge to hospice
LFG2006:
 Transferred from another acute care hospital
Exclusion criteria for primary PCI = Documentation of one or more of the following (Exclusion criteria
for invasive cardiac procedure in settings without full-support services from the ACC/AHA guideline)
 NYHA class III or IV heart failure
 Acute, intermediate, or high risk ischemic syndromes
 Recent myocardial infarction with post infarction ischemia
 Pulmonary edema felt to be caused by ischemia
 Markedly abnormal non-invasive test indicating a high likelihood of left main or
multivessel coronary disease
 Known left main coronary disease
 Severe valvular dysfunction especially in the setting of depressed LV performance
 Other reasons as documented by physician, nurse practitioner, or physician
assistant
Definitions: PCI < 90 minutes = As time (in minutes) from hospital arrival to percutaneous transluminal
coronary angioplasty (PTCA)
PCI-2: Aspirin at arrival
Source: JCAHO (AMI-1)
Numerator: Number of AMI patients who underwent PCI and who received aspirin (or
aspirin/dipyridamole; if aspirin allergic, clopidogrel or ticlopidine) upon arrival.
Denominator: Total number of AMI patients who have undergone PCI and have no contraindications to
any of the above agents.
Principal discharge diagnosis of AMI determined using the following ICD-9 diagnsosis codes for AMI
(Appendix A: AMI Codes from JCAHO website):
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.61
True posterior wall, acute myocardial infarction-initial episode
410.71
Subendocardial, acute myocardial infarction
410.81
Other specified sites, acute myocardial infarction-initial episode
410.91
Unspecified site, acute myocardial infarction-initial episode
And
PCI determined using the following ICD-9 procedure codes as principal or secondary procedure:
00.66
Percutaneous transluminal coronary angioplasty [PTCA] or
coronary atherectomy (code effective 10/1/2005)
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Specifications
36.01
36.02
36.05
36.06
36.07
Single vessel percutaneous transluminal coronary angioplasty
without mention of thrombolytics (code discontinued 10/1/2005)
Single vessel percutaneous transluminal coronary angioplasty with
mention of thrombolytics (code discontinued 10/1/2005)
Multiple vessel PTCA at the same session with or without mention
of thrombolytics (code discontinued 10/1/2005)
Insertion of coronary artery stents
Insertion of drug-eluting coronary artery stent(s)
Exclusions: (as per JCAHO for aspirin in AMI)
 Age < 18 years
 Transferred to another acute care hospital
 Expired during hospitalization
 Left against medical advice
 Discharge to hospice
 Contraindications to aspirin, documentation of one or more of the following: [NOTE:
Patients having one or more of the following contraindications may still potentially
be eligible to receive the medication.]
>Allergy to aspirin
>Active bleeding on admission or during hospitalization
> Warfarin prescribed upon discharge
 Other reasons as documented by physician, nurse practitioner, or physician
Definitions:
Aspirin = oral aspirin and aspirin-containing medications as specified by JCAHO for aspirin in AMI
(Appendix C: Medication Tables from JCAHO website)
Upon discharge = As part of the discharge medications list
PCI-3: Aspirin prescribed at discharge
Source: JCAHO AMI-2
Numerator: Number of AMI patients who underwent PCI and who received aspirin (or
aspirin/dipyridamole; if aspirin allergic, clopidogrel or ticlopidine) upon hospital discharge.
Denominator: Total number of AMI patients who have undergone PCI and have no contraindications to
any of the above agents.
Principal discharge diagnosis of AMI determined using the following ICD-9 diagnsosis codes for AMI
(Appendix A: AMI Codes from JCAHO website):
410.01
Anterolateral wall, acute myocardial infarction-initial episode
410.11
Other anterior wall, acute myocardial infarction-initial episode
410.21
Inferolateral wall, acute myocardial infarction-initial episode
410.31
Inferoposterior wall, acute myocardial infarction-initial episode
410.41
Other inferior wall, acute myocardial infarction-initial episode
410.51
Other lateral wall, acute myocardial infarction-initial episode
410.61
True posterior wall, acute myocardial infarction-initial episode
410.71
Subendocardial, acute myocardial infarction
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Specifications
410.81
410.91
Other specified sites, acute myocardial infarction-initial episode
Unspecified site, acute myocardial infarction-initial episode
And
PCI determined using the following ICD-9 procedure codes as principal or secondary procedure:
00.66
Percutaneous transluminal coronary angioplasty [PTCA] or
coronary atherectomy (code effective 10/1/2005)
36.01
Single vessel percutaneous transluminal coronary angioplasty
without mention of thrombolytics (code discontinued 10/1/2005)
36.02
Single vessel percutaneous transluminal coronary angioplasty with
mention of thrombolytics (code discontinued 10/1/2005)
36.05
Multiple vessel PTCA at the same session with or without mention
of thrombolytics (code discontinued 10/1/2005)
36.06
Insertion of coronary artery stents
Insertion of drug-eluting coronary artery stent(s)
36.07
Exclusions:
LFG2006:
Exclusions: (As per JCAHO for aspirin in AMI)
 Age < 20 years
 Transferred to another acute care hospital
 Expired during hospitalization
 Left against medical advice
 Discharge to hospice
 One or more of the following aspirin contraindications/reasons for not prescribing aspirin
documented in the medical record:
o Aspirin allergy
o Active bleeding on arrival or during hospital stay
o Warfarin/Coumadin prescribed at discharge, or
o Other reasons documented by physician, nurse practitioner, or physician assistant for
not prescribing at discharge
Definitions:
Aspirin = oral aspirin and aspirin-containing medications as specified by JCAHO for aspirin in AMI
(Appendix C: Medication Tables from JCAHO website)
Upon discharge = As part of the discharge medications list
Measurement Guidelines for Aortic Valve Replacement Surgery
JCAHO SCIP-Ind-#c measures are for Other Cardiac Surgery, not AVR, so why AVR procedure codes?
AVS-1: Prophylactic antibiotic selection for other cardiac surgical patients
Source: JCAHO-CMS; NQF Endorsed (SCIP-Inf-2c); see JCAHO specifications manual
Numerator: Number of patients with isolated aortic valve replacement (AVR) surgery who received
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Nationally Endorsed Process Measures
Specifications
prophylactic antibiotics recommended for CABG surgery: cefazolin, cefuroxime, cefarnandole, or
vancomycin* (see approved list JCAHO)
Denominator: Total number of patients with isolated AVR with the following ICD-9-CM Procedure
Codes:
35.21
Replacement of aortic valve with tissue graft
35.22
Other replacement of aortic valve
Exclusions:
 Patients who had a principal or admission diagnosis suggestive of preoperative infectious diseases
(from Appendix A, Table 5.09 for ICD-9-CM codes) need JCAHO link or reference
Principal or admission diagnosis really? suggestive of pre-operative infectious disease:
o Infectious diseases 001.0-139.8
o Meningitis 320.0-326
o Ear Infection 380.0-380.23; 382.0-382.20
o Endocarditis 421.0-422.99
o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1
o Digestive 540-542; 575.0
o Renal 590-590.9; 595.0
o Prostate 601.0-601.9
o Gynecologic 614-614.9 ; 616-616.4
o Skin 680-686.9
o Musculo-skeletal 711.9-711.99; 730.0-730.99
o Fever of unknown origin 780.6
o Septic Shock 785.59
o Bacteremia 790.7
o Viremia 790.8
OR
 Patients who were receiving antibiotics within 24 hours prior to arrival (except colon surgery patients
taking oral prophylactic antibiotics)
 Patients less than 20 years of age
 Patients with physician documented infection prior to surgical procedure of interest
 Patients whose procedure of interest occurred prior to date of admission
*Special consideration: For cardiac and vascular surgery, if patient is allergic to b-lactarn, then
vancomycin or clindarnycin is an acceptable substitute but vancomycin on list, always acceptable?
AVS-2: Prophylactic antibiotic received within 1 hour prior to surgical incision – other cardiac
surgery
Source: JCAHO-CMS-NQF Endorsed (SCIP-Inf-1c); see JCAHO specifications manual
Numerator: Number of patients with isolated isolated aortic valve replacement (AVR) surgery who
received prophylactic antibiotics within one hour of surgical incision (two hours if receiving vancomycin
or fluouroqinolone)
Denominator: Total number of patients with isolated AVR with the following ICD-9-CM procedure
codes:
35.21
Replacement of aortic valve with tissue graft
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35.22
Other replacement of aortic valve
Exclusions:
 Principal or admission diagnosis really? suggestive of pre-operative infectious disease:
o Infectious diseases 001.0-139.8
o Meningitis 320.0-326
o Ear Infection 380.0-380.23; 382.0-382.20
o Endocarditis 421.0-422.99
o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1
o Digestive 540-542; 575.0
o Renal 590-590.9; 595.0
o Prostate 601.0-601.9
o Gynecologic 614-614.9 ; 616-616.4
o Skin 680-686.9
o Musculo-skeletal 711.9-711.99; 730.0-730.99
o Fever of unknown origin 780.6
o Septic Shock 785.59
o Bacteremia 790.7
o Viremia 790.8
OR
 Receiving antibiotics at time of admission
 Medical records do not include antibiotic start date/time or incision date/time
 Receiving antibiotics more than 24 hours prior to surgery
 Patients < 20
AVS-3: Prophylactic antibiotics discontinued within 24 hours after surgery end time – other
cardiac surgery
Source: JCAHO (SCIP-Inf-3c); see JCAHO specifications manual
Numerator: Number of patients with isolated aortic valve replacement (AVR) surgery whose
prophylactic antibiotics were discontinued within 24 hours after surgery end.
Denominator: Total number of patients with isolated AVR with the following ICD-9-CM procedure
codes:
35.21
Replacement of aortic valve with tissue graft
35.22
Other replacement of aortic valve

Principal or admission diagnosis really? suggestive of pre-operative infectious disease:
o Infectious diseases 001.0-139.8
o Meningitis 320.0-326
o Ear Infection 380.0-380.23; 382.0-382.20
o Endocarditis 421.0-422.99
o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1
o Digestive 540-542; 575.0
o Renal 590-590.9; 595.0
o Prostate 601.0-601.9
o Gynecologic 614-614.9 ; 616-616.4
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Specifications
o
o
o
o
o
o
OR




Skin 680-686.9
Musculo-skeletal 711.9-711.99; 730.0-730.99
Fever of unknown origin 780.6
Septic Shock 785.59
Bacteremia 790.7
Viremia 790.8
Receiving antibiotics at time of admission
Medical records do not include antibiotic start date/time or incision date/time
Receiving antibiotics more than 24 hours prior to surgery
Patients < 20
How about these?
 No antibiotics received before or during surgery, or within 24 hours after surgery end-time (i.e., the
patient did not receive antibiotics)
 Diagnosed with and treated for infections within two days after surgery date
 No antibiotics received during the hospitalization
Measurement Guidelines for Elective Abdominal Aortic Aneurysm (AAA) repair
AAA-1: Beta-blocker agent prior to induction
Source: Zynx measure
Numerator: Number of patients undergoing elective AAA who received beta-blockers prior to the time of
induction
Denominator: Total number of patients who underwent elective AAA repair and have no
contraindications to beta-blockers
Principal or secondary discharge diagnosis of Elective AAA Repair determined using the following:
ICD-9 PROCEDURE CODES for non-ruptured AAA
38.24
Resection of aorta with anastomosis
38.44
Resection of aorta, abdominal, with replacement
38.64
Excision of aorta
39.71
Endovascular implantation of graft in abdominal aorta
AND
ICD-9 DIAGNOSIS CODES for unruptured AAA
441.4
Aortic aneurysm without mention of rupture
441.5
Aortic aneurysm of unspecified site without mention of rupture
Exclusions: (as per JCAHO for beta-blockers in AMI)
 <18 years of age
 Transferred to or from another acute care hospital
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Specifications




Expired
Left against medical advice
Discharged to hospice
One or more of the following beta blocker contraindications/reasons for not prescribing a beta blocker
documented in the medical record:
o Beta blocker allergy;
o Bradycardia (heart rate <60 beats per minute) on day of discharge or day prior to discharge while
not on a beta blocker;
o Second or third degree heart block on ECG on arrival or during hospital stay and does not have a
pacemaker;
o Systolic blood pressure <90 mm Hg on day of admission or the previous day, while not on a beta
blocker; or
o Other reasons documented by a physician, nurse practitioner, or physician assistant for not
prescribing a beta blocker at discharge
Definitions:
Beta-blockers = oral or IV (given immediately pre-operative or intra-operative) beta-blockers as specified
by JCAHO for beta-blockers in AMI (Appendix C: Medication Tables from JCAHO website)
Prior to induction = Followed usual treatment regimen if chronic beta-blocker user (eg, taking an oral a.m.
dose of the drug on the day of surgery) or as part of the medication history list on the day of surgery of in
anesthesia record from OR
AAA-2: Beta-blockers prescribed at discharge
Source: Zynx measure
Numerator: Number of patients who underwent AAA repair who received beta-blockers upon hospital
discharge
Denominator: Total number of patients who underwent AAA repair and have no contraindications to
beta-blockers.
Principal or secondary procedure of AAA Repair determined using the following
ICD-9 PROCEDURE CODES
38.24
Resection of aorta with anastomosis
38.44
Resection of aorta, abdominal, with replacement
38.64
Excision of aorta
39.71
Endovascular implantation of graft in abdominal aorta
Exclusions:
(as per JCAHO for beta-blockers in AMI)
 <18 years of age
 Transferred to another acute care hospital
 Expired
 Left against medical advice
 Discharged to hospice
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Specifications

One or more of the following beta blocker contraindications/reasons for not prescribing a beta
blocker documented in the medical record:
o Beta blocker allergy;
o Bradycardia (heart rate <60 beats per minute) on day of discharge or day prior to discharge
while not on a beta blocker;
o Second or third degree heart block on ECG on arrival or during hospital stay and does not have
a pacemaker;
o Systolic blood pressure <90 mm Hg on day of discharge or day prior to discharge, while not on
a beta blocker; or
o Other reasons documented by a physician, nurse practitioner, or physician assistant for not
prescribing a beta blocker at discharge
Definitions:
Beta-blockers = oral beta-blockers as specified by JCAHO for beta-blockers in AMI (Appendix C:
Medication Tables from JCAHO website)
Upon discharge = As part of the discharge medications list
Measurement Guidelines for High-Risk Deliveries
NICU-1: Antenatal steroids
Source: Vermont Oxford Network; see Manual of Operations
Numerator: The number of mothers receiving antenatal steroids prior to birth of a very low birthweight
infant6 or of an infant admitted to the NICU immediately (on day 0) following “in-born” birth.
LFG2006:
Numerator: Number of inborn mothers delivering VLBW infants at 24 through 33 6/7 weeks gestational
age with no contraindications to antenatal steroids and who received at least one dose of antenatal
steroids
Denominator: Total number of mothers delivering either Very Low Birthweight Infants or “in-born”
infants admitted to the NICU immediately (on day 0).
LFG2006:
Denominator: Total number of eligible inborn mothers delivering VLBW infants at 24 through 33 6/7
weeks gestational age and have no contraindications
Very Low Birthweight Infants = Any infant who is born at your hospital and whose birth weight is
between 401 and 1500 grams OR whose gestational age is between 22 weeks 0 days and 29 weeks 6
days (inclusive) is eligible, regardless of where in your hospital the infant receives care. See Tables
4.10, 4.10.1, and 4.11. Vermont Oxford Manual of Operations (see link below)
OR
Any infant whose birth weight is over 1500 grams and who is admitted to a Neonatal intensive care unit
6
VON Manual of Operations 2006, version 10.2, Published Oct 2005, Revised March 9, 2006 and
Revised July 11, 2006.
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(NICU) in your hospital within the first 28 days of life, regardless of gestational age. A NICU is any
location within the hospital in which newborn infants can receive continuous positive airway pressure
(CPAP) or intermittent ventilation (IMV).
See Tables 4.12, and 4.13.
VON Manual of Operations 2006, version 10.2, Published Oct 2005, Revised March 9, 2006 and
Revised July 11, 2006. www.vtoxford.org/tools/2006ManualofOperationsver10_2.pdf
LFG2006:
Principal or secondary discharge diagnosis of Delivery <1500 grams and <32 weeks gestation =
Determined using the following ICD-9 DIAGNOSIS CODES:
764.01-764.05
764.11-764.15
764.21-764.25
764.91-764.95
765.0x
765.10-765.15
Light for dates without mention of malnutrition--< 500 gms. - 1499 gms.
Light for dates with signs of fetal malnutrition--< 500 gms. - 1499 gms.
Fetal malnutrition without mention of light for dates--< 500 gms. - 1499 gms.
Fetal growth retardation, unspecified--< 500 gms. - 1499 gms.
Extreme immaturity (usually BW < 1000 gms. or gestation < 28 weeks)
Other preterm infants, --< 500 gms. – 1499 gms.
AND
765.21-765.26 Gestation age < 33 weeks
Eligible mothers = Mothers of very low birthweight infants (500 – 1500g) who were delivered between 24
and 33 6/7 weeks gestational age, as per the Vermont Oxford Network definition.7
Exclusions: Total number of mothers delivering either Very Low Birthweight Infants or “in-born” infants
admitted to the NICU immediately (on day 0). other than premies/low weight? why steroids for mom?
Babies are “in-born”, not moms; transferred moms should be excluded anyway?
LFG2006:
o Mother’s age < 18 years
o Mother expired during hospitalization
o Transfers in or out
o Contraindications8,9 to administer antenatal steroids to mothers = Documentation of one or more
of the following [NOTE: Patients having one or more of the following contraindications may still
potentially be eligible to receive the medication in which case they should not be excluded as
contraindications.]
 Maternal thyrotoxicosis
 Maternal cardiomyopathy
 Active maternal infection or chorioamnionitis
 Ruptured membrane and imminent delivery 6-12 hours
 Fetal demise
 Mother with tuberculosis
 Other reasons as documented by physician, nurse practitioner, or physician
assistant
7
1999 VON Database Manual of Operations. Release 3.5. VON. Burlington, VT.
American College of Obstetricians and Gynecologists. Antenatal steroid corticosteroid therapy for fetal
maturation. Committee Opinion 147. Washington, D.C.: ACOG, 1994.
9 Steer P, Flint C. ABC of labour care: preterm labour and premature rupture of membranes. BMJ 1999; 318(7190):
1059-1062.
8
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LFG2006:
Antenatal steroids10 = Betamethasone, Dexamethasone. If either agent is not available, hydrocortisone
may help to reduce the incidence of respiratory distress syndrome11,12
10
NIH Consensus Statement 1994 Feb 28-Mar 2;12(2):1-24.
Morrison JC, Whybrew WD, Bucovaz ET, Schneider JM. Injection of corticosteroids into mother to prevent neonatal
respiratory distress syndrome. Am J Obstet Gynecol 1978; 131: 358-366.
12 Morrison JC, Schneider JM, Whybrew WD, Bucovaz ET. Effect of corticosteroids and Fetomaternal disorders on
the L:S ratio. Obstet Gynecol 1980; 56: 583-590.
11
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Frequently Asked Questions
Frequently Asked Questions re: Measuring Adherence for Indicators NOT Reported Nationally
1. I have fewer than 60 cases? Should I measure and report adherence for the indicator(s)?
Yes. Use all the cases that meet the criteria.
2. What is the method that should be used to draw the sample of 60 cases?
Hospitals will need to pull a random sample of more than 60 cases, since some cases will be
eliminated based on the exclusion criteria. The exclusion criteria differ from indicator to indicator, so
you’ll need additional cases for that reason as well. Start by pulling a random sample of cases in
excess of 60. If you need additional cases to make 60 because of the exclusion criteria, just do
another random sample. Hospitals with fewer than 60 cases in total for any procedure should review
all cases.
To sample cases randomly, use a technique that ensures that individual eligible cases in a population
for the entire time period have an equal chance of being selected. Consider using methods similar to
those described by JCAHO. (See JCAHO Sampling Methods)
3. Does this mean that each indicator within the clinical groups will have its own sample of 60?
All will start with a sample size of 60, if at least 60 patients were hospitalized with that condition.
Additional patients may be required depending the number of patients who meet the inclusionary and
exclusionary criteria per indicator.
4. Does this mean that all cases will need to be screened for contraindications and then a
random sample is selected from the remaining records? (Ex. 131 mothers with deliveries at
24-34 weeks, all charts are reviewed and patients with contraindications to steroids are
eliminated. A random sample of 60 is then selected from the remaining cases.)
60 consecutive cases are to be selected, if at least 60 patients were hospitalized with that condition.
Because some of these patients may meet the exclusionary criteria for each indicator, additional
patients may be required to end with 60 patients per indicator who satisfy the inclusionary and
exclusionary criteria. If 60 patients who meet the inclusionary and exclusionary criteria cannot be
identified, please use the total number of eligible patients during that calendar year.
5. Do the inclusion/exclusion criteria apply to both numerator and denominator?
Yes. In fact, for each indicator, you should apply all inclusion/criteria to establish cases in the
denominator first, either all cases meeting those criteria or a sample of 60 if more than 60 meet all the
criteria. The numerator is simply those cases from the denominator that meet the clinical guideline,
and the numerator never includes cases not in the denominator.
CABG – Indicator 6 (early extubation)
6. Virtually all of our patients have at least one of these contraindications to early extubation, so
we won’t have any observations in our denominator.
Not all indicators are appropriate for every hospital. We expect that many patients will meet
exclusionary criteria for early extubation and potentially other indicators.
Percutaneous Coronary Intervention – Indicator 3 (aspirin at discharge)
7. Should expired patients be excluded from the denominator?
Yes.
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Percutaneous Coronary Intervention – Indicator 2 (door-to-balloon time)
8. Should transfers from another facility be excluded from the denominator and numerator?
(JCAHO core measures excludes transfers.)
Yes
9. Would the Expert Panelists convened by Zynx consider redefining its indicators to be
consistent with JCAHO Core Measures (or CMS, AHA measures?) e.g. AAA repair
contraindications are these defined same as Core Measures?
The panelists attempted to be consistent with JCAHO Clinical Core Measure. AAA repair is not a
JCAHO Clinical Core Measure.
10. Can the expert panel indicator for PTCA balloons/average hours turnaround for AMI be
“synchronized” with the JCAHO/CMS/AMA definitions?
The expert panel has attempted to be consistent with JCAHO/CMS definitions for the door-to-balloon
time. (See the Leapfrog-Zynx document of definitions and operational guidelines for the Expert
Panel-Endorsed Process Measures.)
AAA – Indicator 1 (beta-blockers before anesthesia induction)
11. Should transfers from another facility be excluded from the denominator and numerator?
(JCAHO core measures excludes transfers)
Yes
12. The numerator is defined as the number of patients undergoing elective AAA repair who
received beta-blockers “by the time” of induction. What is the defined time period for “by the
time” of induction?
Prior to induction = Followed usual treatment regimen if a chronic beta-blocker user (e.g., taking an
oral a.m. dose of the drug on the day of surgery) or as part of the medication history list on the day of
surgery.
If the patient is a chronic user of beta-blockers, that patient should then receive the regular dose at
the normal period of administration, regardless if the dose should fall on the night prior to surgery or
in the morning before surgery. If the patient is not a chronic user, that patient should then receive
beta-blockers at any time prior to the induction of anesthetics.
13. We counted patients as a yes who took their regular AM dose at home before coming in for
surgery. Is this correct?
Yes.
14. What is the defined time period for “by the time” of induction?
Prior to induction = Followed usual treatment regimen if chronic beta-blocker user (e.g., taking an oral
a.m. dose of the drug on the day of surgery) or as part of the medication history list on the day of
surgery.
If the patient is a chronic user of beta-blockers, that patient should then receive the regular dose at
the normal period of administration, regardless if the dose should fall on the night prior to surgery or
in the morning before surgery. If the patient is not a chronic user, that patient should then receive
beta-blockers at any time prior to the induction of anesthetics.
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AAA – Indicator 2 (beta blocker at discharge)
15. Should expired patients be excluded from the denominator?
Yes.
Neonatal intensive care – Indicator 1 (pre-natal steroids for early-term mother)
16. How do we count a patient transferred here from another facility where they received the
steroids at the other facility? Is this patient excluded from our data since we did not
administer the steroids?
Yes, the patient is excluded from your data.
17. Do we only look at the admission that the patient delivers on? Some preterm patients receive
steroids and are then sent home. They then return at a later date and deliver. Does this count
as a yes?
Yes.
18. We pulled records based on the gestational age at the time of delivery not the age at the time
the steroids were given.
Yes, that is correct.
19. What is the definition for rupture of membranes?
Any breakage of the amniotic sac.
20. Some patients have prolonged premature rupture of membranes and still receive steroids.
Are these patients then excluded?
No. Only patients with premature rupture with imminent delivery within 6-8 hours should be excluded.
21. Some patients who have contraindications still get the steroids. Do we then exclude these
patients from our counts?
Yes.
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