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
|
|
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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