An Environmental Scan of Pay for Performance in the Hospital Setting: Final Report. Appendix C: Inpatient Hospital Measures

11/01/2007

Measure
Organizations Collecting/Utilizing Measures
  Joint Commission CMS1 HQA2 CMS-RHQDAPU3 Premier4 SCIP5 STS6 ACC7 ACE8 GWTG9 IHI10 ACC7 Leapfrog11 NSQIP12 AHRQ13

CDC14

NQF Endorsed

 

IOM
Domain

 

Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time—Other Cardiac Surgery                                        Effectiv  
Pre-Operative Beta Blockade—CABG                                   Effectiv
Arrival  Anti-Platelet Medication at Discharge—CABG                                 Effectiv
Reperfusion Within 90 Minutes of Arrival                             Effectiv Beta Blockade at Discharge—CABG      
 Anti-Lipid lipid Treatment at Discharge—CABG     Effectiv  Inpatient Mortality                       Effectiv  
 Risk-Adjusted Inpatient Operative Mortality—CABG   Safe  30-Day Mortality (Medicare patients)                           Saf  
 Risk-Adjusted Operative Mortality—CABG     Saf  PCI Volum                           Saf  
 Risk-Adjusted Operative Mortality for AVR     Saf  PCI Mortality                         Saf  
 Risk-Adjusted Operative Mortality for MVR   Safe                             Saf  
 Risk-Adjusted Operative Mortality for MVR + CABG       Heart Failure:                           Saf  
 Risk-Adjusted Operative Mortality for AVR + CABG       Discharge Instructions              Saf  
 CABG Inpatient Morality Rate   Effective, Patient  Ctrd.  LVF Assessment  X X       X X      Safe  
 PTCA Mortality Rate   Effective  ACEI or ARB for LVSD            X     Safe
Pregnancy and Related Conditions:                                    
VBAC X                               X Effective
Inpatient Neonatal Mortality X                                 Safe
3rd or 4th Degree Laceration X                               X Safe
Birth Trauma-Injury to Neonat                                   Saf
Obstetric Trauma—Vaginal Delivery with Instrument                                   Saf
Obstetric Trauma—Vaginal Delivery Without Instrument                                   Saf
Obstetric Trauma—Cesarean Delivery                                   Saf
Surgical Care Improvement/ Surgical Infection Prevention:                                    
Prophylactic Antibiotic Received Within 1 Hour Prior to Incision—Overall Rate X   X X X   X         X         X Effective
Prophylactic Antibiotic Received Within 1 Hour Prior to Incision—Hip Arthroplasty X         X X                   X Effective
Prophylactic Antibiotic Received Within 1 Hour Prior to Incision—Knee Arthroplasty X         X X                   X Effective
Prophylactic Antibiotic Received Within 1 Hour Prior to Incision—Colon Surgery                                   Effectiv
Prophylactic Antibiotic Received Within 1 Hour Prior to Incision—Hysterectomy                                   Effectiv
Prophylactic Antibiotic Received Within 1 Hour Prior to Incision—Vascular Surgery                                   Effectiv 
Prophylactic Antibiotic Selection for Surgical Patients—Overall Rate X   X X X   X         X         X Effective
Prophylactic Antibiotic Selection—Hip Arthroplasty X         X X                   X Effective
Prophylactic Antibiotic Selection—Knee Arthroplasty X         X X                   X Effective
Prophylactic Antibiotic Selection—Colon Surgery                                   Effectiv
Prophylactic Antibiotic Selection—Hysterectomy                                   Effectiv
Prophylactic Antibiotic Selection—Vascular Surgery                                   Effectiv
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time—Overall Rate X   X X X   X         X         X Effective
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time—Hip Arthroplasty X         X X                   X Effective
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time—Knee Arthroplasty X         X X                   X Effective
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time—Colon Surgery                                   Effectiv
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time—Hysterectomy                                   Effectiv
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time—Vascular Surgery                                   Effectiv
Recommended VTE Prophylaxis Ordered X   X X X X15                       Effectiv
Recommended VTE Prophylaxis Received Within 24 Hours Prior to or After Surgery X   X X X X15                       Effectiv
Cardiac Surgery Patients with Controlled 6 AM Post-Operative Serum Glucose X   X       X         X           Effective
Surgery Patients with Appropriate Hair Removal                                   Effectiv
Colorectal Surgery Patients with Immediate Post-Operative Normothermia                                   Effectiv
Surgery Patients on Beta Blockers Prior to Admission Who Received a Beta Blocker During the Perioperative Period                                    Effectiv
Mortality Within 30 Days of Surgery                                   Effectiv Safe
ICU:                                    
Ventilator-Associated Pneumonia Prevention—Patient Positioning                                   Effectiv
Ventilator Bundle                       X           Effective
Stress Ulcer Disease Prophylaxis                                   Effectiv
DVT Prophylaxis X                     X           Effective
Central Line Associated Blood Stream Infection                                   Effectiv
Central Line Bundle Compliance                                   Effectiv
Central Line Insertion Adherence Practices                                   Effectiv
Urinary Catheter–Associated Urinary Tract Infection                                    Effectiv
Severe Sepsis/Septic Shock: Activate Drotrecogin Alfa                                   Effectiv
Severe Sepsis/Septic Shock: Low Dose Glucocoticoid                                   Effectiv
Severe Sepsis/Septic Shock: Blood Cultures Collected                                   Effectiv
Severe Sepsis: Central Venous Oxygen Saturation                                   Effectiv
Severe Sepsis: Central Venous Pressure                                   Effectiv
Severe Sepsis/Septic Shock: Glucose Values                                   Effectiv
Severe Sepsis/Septic Shock: Median Inspiratory Plateau Pressures                                    Effectiv
Severe Sepsis/Septic Shock: Median Time to Broad Spectrum Antibiotic                                   Effectiv
Blood Cultures Performed Within 24 Hours Prior to or After Arrival for Patients Transferred to ICU                                   Effectiv
ICU Length of Sta                                   Effectiv Efficient
Hospital Mortality for ICU Patients                                   Effectiv Safe
Stroke:                                    
Deep Vein Thrombosis (DVT) Prophylaxis (Ischemic)                                   Effectiv
DVT Prophylaxis for Intercranial Hemorrhage                                   Effectiv
Discharged on Antithrombotics (Ischemic, TIA)                                   Effectiv
Discharged on Antiplatelet Therapy                                   Effectiv
Patients with Atrial Fibrillation Receiving Anticoagulation Therapy (Ischemic)                                   Effectiv
Tissue Plasminogen Activator (t-PA) Considered (Ischemic, TIA)                                   Effectiv
Antithrombotic Medication Within 48 Hours of Hospitalization (Ischemic, TIA)                                   Effectiv
Lipid Profile (Ischemic, TIA                                   Effectiv
Screen for Dysphagia (Ischemic, Hemorrhagic, TIA)                                   Effectiv
Stroke Education (Ischemic, Hemorrhagic, TIA)                                   Effectiv Patient Ctrd.
Smoking Cessation (Ischemic, Hemorrhagic, TIA)                                   Effectiv Patient Ctrd.
Plan for Rehabilitation Considered (Ischemic, Hemorrhagic)                                   Effectiv
                                    Patient Ctrd.
Lipids Measured                     X             Effective
Blood Pressure Management                     X             Effective
Non-Invasive Cartoid Imaging Reports                                   Effectiv
CT or MRI Report                                   Effectiv
Avoidance of Intravenous Heparin                                   Effectiv
Acute Stroke In-Hospital Mortality Rates                                   Saf
Cardiac Surgery:                                    
Participation in a Systematic Database for Cardiac Surgery (STS)                                   Effectiv
Surgical Volume—Isolated CABG                                   Saf
Surgical Volume—Valve Surgery                                   Saf
Surgical Volume—CABG + Valve Surgery                                   Saf
Prophylactic Antibiotic Within 1 Hour Prior to Surgical Incision—CABG                                   Effectiv
Prophylactic Antibiotic Within 1 Hour Prior to Surgical Incision—Other Cardiac Surgery                                   Effectiv
Selection of Antibiotic—CABG X         X X                   X Effective
Selection of Antibiotic—Other Cardiac Surgery                                   Effectiv
Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time—CABG                                    
Use of Internal Mammary Artery—CABG                                   Effectiv
Aspirin at Discharge—CABG           X             X          
Post-Operative Hemorrhage or Hematoma—CABG                                    
Post-Operative Physiologic and Metabolic Derangement                                    
Prolonged Intubation—CABG               X                 X Effective
Deep Sternal Wound Infection Rate—CABG                                   Saf
Stroke/Cerebrovascular Accident—CABG                                   Saf
Post-Operative Renal Insufficiency—CABG                                   Saf
Surgical Re-exploration—CABG                                   Saf
Cartoid Endarterectomy Mortality Rate                                   Saf
Bilateral Cardiac Catheterization Rate                                   Saf
Surgery (Non-Cardiac):                                    
Complications of Anesthesia                             X     Safe
Failure to Rescue X                           X     Safe
Foreign Body Left in During Procedure                                   Saf
Post-Operative Hip Fracture                             X     Safe
Post-Operative Hemorrhage or Hematoma           X15                       Saf
Post-Operative Physiologic and Metabolic Derangements           X15                       Saf
Readmissions 30 Days Post-Discharge           X15                       Safe Efficient
                                        Safe Surgical Site Infection          
Surgical Wound Disruptio                                   Saf
Post-Operative Respiratory Failure                                   Saf
Post-Operative Pulmonary Embolism or Deep Vein Thrombosis                                   Saf
Post-Operative Sepsi                                   Saf
Post-Operative Wound Dehiscence                                   Saf
Hip Replacement Mortality Rate                                   Saf
Esophageal Resection Mortality Rate                                   Saf
Pancreatic Resection Mortality Rate                                   Saf
AAA Repair Mortality Rate                             X     Safe
Incidental Appendectomy Among Elderly Rate                                   Saf
Laparoscopic Cholecystectomy Rate                                   Saf
Other Surgical Wound Occurrence                                   Saf
Pneumonia Post-Surgery                           X       Safe
Unplanned Intubation                           X       Safe
Pulmonary Embolis                                   Saf
On Ventilator > 48 Hours                           X       Safe
Other Respiratory Occurrences                           X       Safe
Progressive Renal Insufficiency                           X       Safe
Acute Renal Failur                                   Saf
Urinary Tract Infection                           X       Safe
Other Urinary Tract Occurrence                            X       Safe
CVA/Strok                                   Saf
Com                                   Saf
Peripheral Nerve Injury                           X       Safe
Other CNS Occurrence                           X       Safe
Cardiac Arrest Requiring CPR                           X       Safe
Myocardial Infarction                           X       Safe
Other Cardiac Occurrence                           X       Safe
Bleeding Requiring > 4 Units PRBC/Whole Blood Transfusions Within the First 72 Hours Post-Operative                                   Saf
Surgical Graft/Prosthesis/Flap Failure                                   Saf
DVT/Thrombophlebitis                           X       Safe
Systemic Sepsis (SIRS)                           X       Safe
Systemic Sepsis (Sepsis)                           X       Safe
Systemic Sepsis (Septic Shock)                           X       Safe
Other Occurrences                           X       Safe
Return to the Operating Room Within 30 Days of Surgery                                   Saf
Death Within 30 Days of Surgery                                   Saf
Death Greater Than 30 Days After Surgery in Acute Care                                   Saf
Venous Thromboembolism (VTE):                                    
Risk Assessment/Prophylaxis Within 24 Hours of Admission                                   Effectiv
Risk Assessment/Prophylaxis Within 24 Hours of Transfer to ICU                                   Effectiv
Documentation of Inferior Vena Cava Filter Indication                                   Effectiv
VTE Patients with Overlap Therapy                                   Effectiv
VTE Patients Receiving Heparin-Platelet Count Monitoring                                   Effectiv
VTE Discharge Instructions X                                 Effective
Incidence of Potentially Preventable Hospital-Acquired VTE                                   Effectiv Safe
VTE 30-Day Hospital Readmission (ICSI)                                   Effectiv Efficient
Cancer:                                    
Patients with Early Stage Breast Cancer Who Have Evaluation of the Axilla                                   Effectiv
College of American Pathologists Breast Cancer Protocol                                   Effectiv
Colon Cancer: Surgical Resection Includes at Least 12 Nodes                                    Effectiv
College of American Pathologists Colon and Rectum Protocol                                   Effectiv
Completeness of Pathologic Reporting                                   Effectiv

 

Measure
Organizations Collecting/Utilizing Measures
  Joint Commission CMS1 HQA2 CMS-RHQDAPU3 Premier4 SCIP5 STS6 ACC7 ACE8 GWTG9 IHI10 Leapfrog11 NSQIP12 AHRQ13 CDC14 NQF En-dorsed IOM Domain
Nursing/General Care:                                  
Death Among Surgery Inpatients with Treatable Serious Complications                                 Saf
Pressure Ulcer Prevalence X                         X   X Safe
Falls Prevalenc                                 Saf
Falls with Injur                                 Saf
Restraint Prevalence (Vest and Limb Only)                                 Saf
Influenza Vaccination for Healthcare Workers                                 Saf
Patient Safety (Non-Surgical):                                  
Death in Low Mortality DRG                                 Saf
Decubitis Ulcers                           X     Safe
Failure to Rescue                           X     Safe
Iatrogenic Pneumothora                                 Saf
Selected Infections due to Medical Care                                 Saf
Transfusion Reactio                                 Saf
GI Hemorrhage In-Hospital Mortality Rate                                 Saf
Hip Fracture In-Hospital Mortality Rate                                 Saf
Structural:                                  
Nursing Care Hours per Patient Day                                 Effectiv Safe
Nursing Skill Mix (RN, LVN, LPN, UAP, and Contract)                                 Effectiv Safe
Nursing Practice Environment X                             X Safety
Nursing Voluntary Turnove                                 Safet
Computer Physician Order Entry                                  Saf
ICU Physician Staffing (Intensivist)                                 Saf
Evidence-Based Hospital Referral                                 Saf
NQF Safe Practice                                 Saf
Psychiatric Services:                                  
Assessment of Violence Risk, Substance Use Disorder, Trauma, and Patient Strengths                                 Effectiv Safe, Patient Ctrd.
Hours of Restraint Us                                 Saf
Hours of Seclusion Use X                               Safe
Patients Discharged on Multiple Antipsychotic Medications                                 Effectiv Safe
Discharge Assessment and Aftercare Recommendations Sent to Next Level of Care upon Discharge                                 Effectiv

 

Measure
Organizations Collecting/Utilizing Measures
  Joint Commission CMS1 HQA2 CMS-RHQDAPU3 Premier4 SCIP5 STS6 ACC7 ACE8 GWTG9 IHI10 Leapfrog11 NSQIP12 AHRQ13 CDC14 NQF En-dorsed IOM Domain
Care Coordination:                                  
3 Item Care Transition                                 Effectiv Patient Ctrd.
Patient Experience:                                  
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) X X X X                   X     Patient Ctrd.
Cross-Cutting Length of Stay/Readmission:                                  
Inpatient Hospital Average Length of Stay by Medical Service (Pacificare)                                 Efficien
Risk-Adjusted Average Length of Inpatient Stay (CareScience)                                  
Severity-Standardized Average Length of Stay, Routine Care                       X          
Severity-Standardized Average Length of Stay, Special Care                                  
14 Day All-Cause Readmission Rate                                   
Inpatient Readmission Rate by Medical Diagnosis (Pacificare)                                  

1 Center for Medicare and Medicaid Services

2 Hospital Quality Alliance

3 Reporting Hospital Quality Data for Annual Payment Update 

4 Premier Hospital Quality Incentive Demonstration

5 Surgical Care Improvement Project

6 The Society of Thoracic Surgeons   

7 American College of Cardiology

8 Alliance for Cardiac Care Excellence

9 Get With the Guidelines

10 Institute for Healthcare Improvement

11 The Leapfrog Group

12 National Surgical Quality Improvement Program

13 Agency for Healthcare Research and Quality

14 Center for Disease Control

15 These Premier measures apply only to Hip and Knee Replacement.

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