NQF Endorses Additional Set of Complication-Related Patient Safety Measures 

DEC 17, 2012

CONTACT: Erin Weireter, NQF

NQF Endorses Additional Set of Complication-Related Patient Safety Measures

Washington, DC – The National Quality Forum (NQF) Board of Directors has endorsed 12 patient safety measures with a focus on complications. The measures address a range of quality concerns, including falls, pressure ulcers, and healthcare-associated infections.

The measures were evaluated as part of NQF’s patient safety endorsement project, which previously endorsed measures related to medication safety, surgical safety, and care coordination, as well as venous thromboembolism and medication documentation, in June and August 2012, respectively.

“Protecting patients from harm is at the heart of NQF’s work to improve healthcare quality,” said Helen Burstin, MD, MPH, senior vice president for performance measures at NQF. “These endorsed measures will have a significant impact on national patient safety efforts by helping providers measure, report on, and ultimately improve the care they deliver.”

Falls and pressure ulcers are considered high-cost and high-volume adverse events. Falls are the leading cause of injury-related death for individuals aged 65 and older, and it is estimated that patient falls among the elderly will cost over $30 billion by 2020.1,2 Furthermore, there were 257,412 reported cases of Medicare patients who had a pressure ulcer as a secondary diagnosis during hospitalization in 2007, resulting in average healthcare costs of $43,180 per patient.3 

“The healthcare community is dedicated to improving patient safety and reducing preventable harm, and quality measurement is integral to this effort,” said Pamela Cipriano, PhD, RN, senior director at Galloway Consulting and co-chair of the Patient Safety – Complications Steering Committee. “These measures – rigorously evaluated and focused on some of the most pressing care concerns – give providers the tools they need to effectively evaluate and advance high-quality care.”

The measures include those that have been endorsed for at least three years and are now undergoing NQF endorsement maintenance. The ongoing evaluation and updating of endorsed measures ensures they are current, “best in class,” address gaps in existing measures, are synchronistic with national priorities, and enhance NQF’s patient safety portfolio. In all, 21 measures were submitted for evaluation against NQF’s endorsement criteria. Twelve measures – including two new submissions – were endorsed.

“The U.S. healthcare system has made great strides in improving patient safety, yet too many patients still suffer preventable harm,” said William A. Conway, MD, senior vice president and chief quality officer at Henry Ford Health System and co-chair of the Patient Safety – Complications steering committee. “These endorsed measures, addressing some of the most prevalent and devastating complications in care, will be critical to ensuring patients receive safe, compassionate, and high-quality care.”

NQF is a voluntary consensus standards-setting organization. Any party may request reconsideration of any of the 12 endorsed quality measures listed below by submitting an appeal no later than January 15 (to submit an appeal, go to the NQF Measure Database). For an appeal to be considered, the notification must include information clearly demonstrating that the appellant has interests directly and materially affected by the NQF-endorsed recommendations and that the NQF decision has had (or will have) an adverse effect on those interests.

Endorsed Measures: 

  • 0035: Fall risk management (NCQA)
  • 0101: Falls: screening, risk-assessment, and plan of care to prevent future falls (NCQA)
  • 0266: Patient fall (Ambulatory Surgical Centers Quality Collaborative)
  • 0537: Multifactor fall risk assessment conducted in patients 65 and older (CMS)
  • 0538: Pressure ulcer prevention and care (CMS)
  • 0337: Pressure ulcer rate (PDI 2) (AHRQ)
  • 0347: Death rate in low-mortality diagnosis related groups (PSI 2)(AHRQ)
  • 0204: Skill mix (Registered Nurse [RN], Licensed Vocational/Practical Nurse [LVN/LPN], Unlicensed Assistive Personnel [UAP], and contract)(American Nurses Association)
  • 0205: Nursing hours per patient day (American Nurses Association)
  • 0206: Practice Environment Scale – Nursing Work Index (PES-NWI) (composite and five subscales)(The Joint Commission)
  • 1716: National Healthcare Safety Network (NHSN) facility-wide inpatient hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia outcome measure (CDC)
  • 1717: National Healthcare Safety Network (NHSN) facility-wide hospital-onset Clostridium difficile Infection (CDI) outcome measure (CDC) 

NQF operates under a three-part mission to improve the quality of American healthcare by:  

  • building consensus on national priorities and goals for performance improvement and working in partnership to achieve them;  
  • endorsing national consensus standards for measuring and publicly reporting on performance; and  
  • promoting the attainment of national goals through education and outreach programs. 
  1. CDC, 2006: Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at http://www.cms.hhs.gov/hospitalacqcond/. Last accessed October 30, 2009.
  2. UlrichR, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
  3. Armstrong DG, Ayello EA, Capitulo KL, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission indicators/hospital-acquired conditions policy -- a consensus paper from the International Expert Wound Care Advisory Panel. Adv Skin Wound Care 2008; 21:469-470, 472-478.