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	X				X								Effectiv
Risk-Adjusted Inpatient Operative Mortality—CABG	X		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								X					Saf
Risk-Adjusted Operative Mortality for MVR	X		Safe														Saf
Risk-Adjusted Operative Mortality for MVR + CABG				Heart Failure:													Saf
Risk-Adjusted Operative Mortality for AVR + CABG				Discharge Instructions	X	X	X	X	X				X	X			Saf
CABG Inpatient Morality Rate	X		Effective, Patient Ctrd.	LVF Assessment	X X	X	X	X	X				X	X X			Safe
PTCA Mortality Rate	X		Effective	ACEI or ARB for LVSD	X	X	X	X	X						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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An Environmental Scan of Pay for Performance in the Hospital Setting: Final Report. Appendix C: Inpatient Hospital Measures

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