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Heart Attack
Heart Failure
Pneumonia
Surgical Care Improvement
Error Prevention
Inpatient Quality Indicators (IQI)
Patient Experience of Care Survey (HCAHPS Survey)
Birth
Stroke
Health Care Associated Infections
CMS 30-Day Mortality
CMS 30-Day Readmissions

Detailed Technical Measure Specifications can be found at: https://www.qualitynet.org/

Heart Attack

  • Aspirin at discharge (AMI-2) – Percent of heart attack patients that are prescribed an aspirin when they are discharged from the hospital
  • Percutaneous Coronary Intervention (PCI) Performed With 90 Minutes of Arrival (AMI-8a) - Percent of heart attack patients given PCI within 90 Minutes after they arrive at hospital.
  • Thrombolytic Medication Within 30 Minutes of Arrival (AMI-7a) - Percent of heart attack patients given thrombolytic medications within 30 minutes of arrival.
Heart Failure
  • Left Ventricular Function (LVF) assessment (HF-2) – Percent of heart failure patients that are given a test to assess the function of their heart before, during or soon after discharge from the hospital.
  • ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) (HF-3) – Percent of congestive heart failure patients with low heart function that are prescribed an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB) medication when they are discharged from the hospital.
  • Discharge Instructions (HF-1) – Percent of heart failure patients discharged to home with written instructions to the patient or caregiver that addresses all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.
Pneumonia
  • Appropriate Antibiotic (PN-6) – Percent of immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines
  • Blood Culture Collected (PN-3b) – The percent of pneumonia patients who had their blood culture taken prior to their first dose of antibiotics.

Surgical Care Improvement

  • Surgical Care Improvement Index - The percent of surgical patients that were given all the care they needed based on the process of care measures we collect for this condition.
  • All Procedures–Start Antibiotic (SCIP-Inf-1a) – Percent of all applicable surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
  • All Procedures-Appropriate Antibiotic (SCIP-Inf-2a) – Percent of all applicable surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • All Procedures-Stop Antibiotics (SCIP-Inf-3a) – Percent of all applicable surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
  • Blood Sugar Controlled (SCIP-Inf-4) – Percent of patients that had cardiac surgery whose blood sugar was under control at 6 a.m. on the first two days following surgery.
  • Catheter Removal (SCIP-Inf-9) – Percent of surgery patients whose urinary catheter was removed within two days following surgery.
  • Temperature Management (SCIP-Inf-10) – Percent of surgery patients who had an active warming device used during their surgery or had a normal body temperature immediately before or after their surgery.
  • Beta Blocker Received (SCIP-Card-2) – Percent of surgery patients who were on a cardiac beta blocker medication prior to arrival at the hospital who received that medication on the day of surgery, through two days following surgery.
  • Clot Prevention Given (SCIP-VTE-2) – Percent of surgery patients who were given a prophylactic medication to prevent deep vein thrombosis or pulmonary embolism, when indicated, within 24 hours of surgery.
  • Hip Surgery: Initial Antibiotic (SCIP-INF-1d) – Percent of hip surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
  • Hip Surgery: Appropriate Antibiotic (SCIP-INF-2d) – Percent of hip surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • Hip Surgery: Stop Antibiotic (SCIP-INF-3d) – Percent of hip surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
  • Knee Surgery: Initial Antibiotic (SCIP-INF-1e) – Percent of knee surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
  • Knee Surgery: Appropriate Antibiotic (SCIP-INF-2e) – Percent of knee surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • Knee Surgery: Stop Antibiotic (SCIP-INF-3e) – Percent of knee surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
  • Other Cardiac Surgery: Initial Antibiotic (SCIP-INF-1c) – Percent of other cardiac surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
  • Other Cardiac Surgery: Appropriate Antibiotic (SCIP-INF-2c) – Percent of other cardiac surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • Other Cardiac Surgery: Stop Antibiotic (SCIP-INF-3c) – Percent of other cardiac surgery patients whose prophylactic antibiotics were discontinued within 48 hours after surgery end time.
  • Coronary Artery Bypass Graft (CABG): Initial Antibiotic (SCIP-INF-1b) – Percent of CABG patients who received prophylactic antibiotics within one hour prior to surgical incision.
  • Coronary Artery Bypass Graft (CABG): Appropriate Antibiotic (SCIP-INF-2b) – Percent of CABG surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • Coronary Artery Bypass Graft (CABG): Stop Antibiotic (SCIP-INF-3b) – Percent of CABG patients whose prophylactic antibiotics were discontinued within 48 hours after surgery end time.
  • Vascular Surgery: Initial Antibiotic (SCIP-INF-1h) – Percent of vascular surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
  • Vascular Surgery: Appropriate Antibiotic (SCIP-INF-2h) – Percent of vascular surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • Vascular Surgery: Stop Antibiotic (SCIP-INF-3h) – Percent of vascular patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
  • Colon Surgery: Initial Antibiotic (SCIP-INF-1f) – Percent of colon surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
  • Colon Surgery: Appropriate Antibiotic (SCIP-INF-2f) – Percent of colon surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • Colon Surgery: Stop Antibiotic (SCIP-INF-3f) – Percent of colon surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
  • Hysterectomy Surgery: Initial Antibiotic (SCIP-INF-1g) – Percent of hysterectomy surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
  • Hysterectomy Surgery: Appropriate Antibiotic (SCIP-INF-2g) – Percent of hysterectomy surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
  • Hysterectomy Surgery: Stop Antibiotic (SCIP-INF-3g) - Percent of hysterectomy surgery patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time.
Stroke
  • Anti-thrombotics on Discharge (STK-2) – Percent of ischemic stroke patients who are prescribed antithrombotic therapy at hospital discharge.
  • Anticoagulant for Atrial Fibrillation/Flutter (STK-3) – Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge.
  • Early Antithrombotic Therapy (STK-5) – Percent of ischemic stroke patients who received antithrombotic therapy by the end of their second day in the hospital.
  • Discharged on Statin Medication (STK-6) – Percent of ischemic stroke patients with a high lipid level (LDL>100) who are prescribed a lipid lowering medication (statin) at discharge.
  • Stroke Education (STK-8) - Percent of stroke patients or their caregivers who received education about activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke and early warning signs and symptoms of stroke.
  • Assessment for Rehabilitation (STK-10) – Percent of stroke patients who were assessed for rehabilitation services.
Error Prevention
  • Site Marking – Percent that indicates the completeness of a process to mark the site of eligible surgical and invasive procedures that includes the patient in the site marking.
  • Procedure Verification – Percent that indicate the completeness of a process to verify the correct patient, procedure(s) and site(s) prior to the start of all surgical or invasive procedures.
  • Medication Reconciliation at Discharge – Percent that indicates progress towards obtaining the most accurate list of each patient's current medications and then, making sure that each medication is addressed when a patient is discharged from the hospital.
CMS 30-Day Mortality
These measures reflect the percent of patients who die within 30 days of being admitted to a hospital. The rates take into account how sick the patient was before they were admitted. The measures include patients who were admitted for:
  • Heart Attack
  • Heart Failure
  • Pneumonia
CMS 30-Day Readmissions
These measures reflect the percent of patients who had a recent hospital stay who had to go back into a hospital within 30 days of their discharge. The rates take into account how sick the patient was before they were admitted. The measures include patients who were admitted for:
  • Heart Attack
  • Heart Failure
  • Pneumonia
Health Care Associated Infections
  • CLABSI – Central Line Associated Blood Stream Infections – Standardized infection ratio (SIR) which compares how a single hospital’s number of central line associated blood stream infections, for patients in intensive care units, compares to a national standard. The national standard is reported by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN).
  • CAUTI – Catheter Associated Urinary Tract Infections - Standardized infection ratio (SIR) which compares how a single hospital’s number of catheter associated urinary tract infections, compares to a national standard. The national standard is reported by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN).
  • SSI – Surgical Site Infections – Colon Surgery - Standardized infection ratio (SIR) which compares how a single hospital’s number of surgical site infections, for colon surgery, compares to a national standard. The national standard is reported by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN).
  • SSI – Surgical Site Infections – Abdominal Hysterectomy - Standardized infection ratio (SIR) which compares how a single hospital’s number of surgical site infections, for abdominal hysterectomy surgery, compares to a national standard. The national standard is reported by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN).
Inpatient Quality Indicators (IQI)
The Inpatient Quality Indicators include three distinct types of measures. Volume measures examine the volume of inpatient procedures for which a link has been demonstrated between the number of procedures performed and outcomes such as mortality. In-hospital mortality measures examine outcomes following procedures and for common medical conditions. Utilization examines procedures for which questions have been raised about overuse, underuse, and misuse.

There are many factors that determine the results in a mortality report. The data analysis method adjusts for some of these factors, but not all. For example, when a patient has a “Do Not Resuscitate (DNR)” order in place, the hospital must honor that, and our data analysis method cannot tell the difference between a death that occurs with a DNR order in place and one that occurs from some other cause.
Patient Experience of Care Survey (HCAHPS Survey)

The Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) survey includes 27 questions that are used to report 10 measures (six summary, two individual and two global measures) that reflect the patient’s perception of the care that they have received in the hospital.
  • Overall Ranking
  • Would Recommend
  • Doctor Communication
  • Nurse Communication
  • Patient Received Help in a Timely Manner
  • Explanations of Medications
  • Pain Control
  • Quietness at Night
  • Room Cleanliness
  • Discharge Instructions
Birth
  • Pre-birth Steroids – Percent of preterm pregnancies that received at least one dose of antenatal steroids.
  • Forceps Delivery – Percent of infants with a vaginal birth, delivered in a hospital where a forceps was used.
  • Vacuum Delivery – Percent of inborn deliveries with a vaginal birth where a vacuum extractor was used.
  • Breast Feeding – Percent of infants breast feeding at discharge. This measure includes exclusive breastfeeding plus a combination of breastfeeding plus other feedings.
  • Infant Composite – Percent of full term, live born infants without major congenital anomalies that met the National Center for Health Statistics significant birth injury criteria, had a 5 minute APGAR score less than 7, needed mechanical ventilation or resulted in neonatal death.
No data collected at this time or no cases met criteria?

See "Measure Key"

Data collected, but the report shows a "+" sign in the report?

See "Measure Key"


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