| Day 1 |
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|
|
| 8:00 am |
Breakfast |
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|
| 8:30 am |
Welcome, Review Meeting Objectives, and Pre-Rulemaking Approach |
|
Frank Opelka, Workgroup Chair; Ron Walters, Workgroup Co-Chair;
Taroon Amin, Senior Director, NQF
|
| 8:45 am |
Measures Under Consideration for Hospital Outpatient Quality
Reporting Program |
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|
| |
OQR Calendar 1: Support |
|
|
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Programs Under Consideration: Hospital Outpatient Quality Reporting
Program
|
|
Lead Discussant(s): Jamie Brooks Robertson, David Engler |
|
- Advance Care Plan (MUC ID: E0326)
Description:
Percentage of patients aged 65 years and older who have an advance care
plan or surrogate decision maker documented in the medical record or
documentation in the medical record that an advance care plan was
discussed but the patient did not wish or was not able to name a
surrogate decision maker or provide an advance care plan. [Description
differs from posted MUC list based on NQF staff analysis]
Notes:
- External Beam Radiotherapy for Bone Metastases (MUC ID:
E1822)
Description: This measure reports the percentage of
patients, regardless of age, with a diagnosis of painful bone metastases
and no history of previous radiation who receive external beam radiation
therapy (EBRT) with an acceptable fractionation scheme as defined by the
guideline.
Notes:
- Health literacy measure derived from the health literacy domain
of the C-CAT (MUC ID: E1898)
Description: 100 measure of
health literacy related to patient-centered communication, derived from
items on the staff and patient surveys of the Communication Climate
Assessment Toolkit
Notes:
|
|
Notes on Session:
|
| |
OQR Calendar 2: Conditional support pending NQF endorsement |
|
|
|
Programs Under Consideration: Hospital Outpatient Quality Reporting
Program
|
|
Lead Discussant(s): Daniel Pollock, Richard Bankowitz |
|
- Use of Brain Computed Tomography (CT) in the Emergency Department
for Atraumatic Headache (MUC ID: X607)
Description: This
measure calculates the percentage of Emergency Department (ED) visits
for atraumatic headache with a coincident brain computed tomography (CT)
study for Medicare beneficiaries.
Notes:
|
|
Notes on Session:
|
| |
OQR Calendar 3: Conditional support pending the development of the
single composite measure |
|
|
|
Programs Under Consideration: Hospital Outpatient Quality Reporting
Program
|
|
Lead Discussant(s): Kelly Trautner, Michael Phelan |
|
- Administrative Communication (MUC ID:
E0291)
Description: Percentage of patients transferred to
another healthcare facility whose medical record documentation indicated
that administrative information was communicated to the receiving
facility within prior to departure
Notes:
- Medication Information (MUC ID: E0293)
Description:
Percentage of patients transferred to another HEALTHCARE FACILITY whose
medical record documentation indicated that medication information was
communicated to the receiving FACILITY within 60 minutes of departure
Notes:
- Vital Signs (MUC ID: E0292)
Description: Percentage
of patients transferred to another HEALTHCARE FACILITY whose medical
record documentation indicated that the entire vital signs record was
communicated to the receiving FACILITY within 60 minutes of departure
Notes:
- Nursing Information (MUC ID: E0296)
Description:
Percentage of patients transferred to another HEALTHCARE FACILITY whose
medical record documentation indicated that nursing information was
communicated to the receiving FACILITY within 60 minutes of departure
Notes:
- Procedures and Tests (MUC ID: E0297)
Description:
Percentage of patients transferred to another healthcare facility whose
medical record documentation indicated that procedure and test
information was communicated to the receiving FACILITY within 60 minutes
of departure
Notes:
- Physician Information (MUC ID: E0295)
Description:
Percentage of patients transferred to another HEALTHCARE FACILITY whose
medical record documentation indicated that physician information was
communicated to the receiving FACILITY within 60 minutes of departure
Notes:
- Patient Information (MUC ID: E0294)
Description:
Percentage of patients transferred to another HEALTHCARE FACILITY whose
medical record documentation indicated that patient information was
communicated to the receiving FACILITY within 60 minutes of departure
Notes:
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|
Notes on Session:
|
| |
OQR Calendar 4 (Under Development): Encouraged for continued
development |
|
|
|
Programs Under Consideration: Hospital Outpatient Quality Reporting
Program
|
|
Lead Discussant(s): Amanda Stefancyk Oberlies, Jack Fowler |
|
- O/ASPECS Overall Facility Rating (MUC ID:
X3702)
Description: Survey Question: Using any number from 0
10 10, where 0 is the worst facility possible and 10 is the best
facility possible, what number would you use to rate this facility?
Notes:
- O/ASPECS Recommend (MUC ID: X3703)
Description:
Survey question: Would you recommend this facility to your friends and
family? Response options: Definately no, Probably no, Probably yes,
Definately yes.
Notes:
- O/ASPECS About Facility and Staff (MUC ID:
X3698)
Description: Multi-item measure: P1: "When you arrived
at this facility on the day of your procedure, did the check-in process
run smoothly?" P2: "Was the facility clean?" P3: "Were the clerks and
receptionists at the facility as helpful as you thought they should be?"
P4: "Did the clerks and receptionists at the facility treat you with
courtesy and respect?" P5: "Did the doctors, nurses and other staff
treat you with courtesy and respect?" P6: "Did the doctors, nurses and
other staff make sure you were as comfortable as possible?"
Notes:
- O/ASPECS Communication (MUC ID: X3699)
Description:
Multi-item measure: P1: “Did your doctor or anyone from the facility
give you all the information you needed about your procedure?” P2: “Did
your doctor or anyone from the facility give you easy to understand
instructions about getting ready for your procedure?” P3: “Did the
doctors, nurses and other staff explain things about your procedure in a
way that was easy for you to understand?” P4 “Did your doctor or anyone
from the facility explain the process of giving anesthesia in a way that
was easy to understand? P5: “Did your doctor or anyone from the
facility explain the possible side effects of the anesthesia in a way
that was easy to understand?
Notes:
- O/ASPECS Discharge and Recovery (MUC ID:
X3697)
Description: Multi-item measure: P1: “Discharge
instructions include things like symptoms you should watch out for after
your procedure, instructions about your medicines, and home care. Before
you left the facility, did you receive written discharge instructions?”
P2: “Did your doctor or anyone from the facility prepare you for what
to expect during your recovery?” P3: “Ways to control pain can include
prescription medicine, over-the-counter pain relievers or ice packs, for
example. Did your doctor or anyone from the facility give you
information about what to do if you had pain as a result of your
procedure” (of those that had pain as a result of the procedure). P4:
“Before you left, did your doctor or anyone from the facility give you
information about what to do if you had nausea or vomiting” (of those
that had either nausea or vomiting as a result of either your
procedure or anesthesia). P5: “Before you left, did your doctor or
anyone from the facility give you information about what to do if you
had bleeding as a result of your procedure” (of those that had bleeding
as a result of the procedure). P6: “Possible signs of infection
include fever, swelling, heat, drainage or redness. Before you left, did
your doctor or anyone from the facility give you information about what
to do if you had possible signs of infection (of those having signs of
infection as a result of the procedure).
Notes:
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|
Notes on Session:
|
| 9:45 am |
Measures Under Consideration for Ambulatory Surgical Center Quality
Reporting |
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| |
ASCQR Calendar 1: Support |
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|
|
Programs Under Consideration: Ambulatory Surgical Centers Quality
Reporting Program
|
|
Lead Discussant(s): R. Sean Morrison, Helen Haskell |
|
- Advance Care Plan (MUC ID: E0326)
Description:
Percentage of patients aged 65 years and older who have an advance care
plan or surrogate decision maker documented in the medical record or
documentation in the medical record that an advance care plan was
discussed but the patient did not wish or was not able to name a
surrogate decision maker or provide an advance care plan. [Description
differs from posted MUC list based on NQF staff analysis]
Notes:
|
|
Notes on Session:
|
| |
ASCQR Calendar 2: Conditional support pending the completion of
reliability testing and NQF endorsement |
|
|
|
Programs Under Consideration: Ambulatory Surgical Centers Quality
Reporting Program
|
|
Lead Discussant(s): Donna Slosburg, Cristie Travis |
|
- Unplanned Anterior Vitrectomy (MUC ID:
X3720)
Description: This measure evaluates the number of
cataract surgery patients who have an unplanned anterior vitrectomy
Notes:
- Normothermia Outcome (MUC ID: X3719)
Description:
This measure evaluates whether patients having surgical procedures under
general or neuraxial anesthesia of 60 minutes or more in duration are
normothermic within 15 minutes of arrival in PACU
Notes:
|
|
Notes on Session:
|
| |
ASCQR Calendar 3: Do Not Support |
|
|
|
Programs Under Consideration: Ambulatory Surgical Centers Quality
Reporting Program
|
|
Lead Discussant(s): Mitchell Levy, Martin Hatlie |
|
- Ambulatory surgery patients with appropriate method of hair
removal (MUC ID: E0515)
Description: Percentage of ASC
admissions with appropriate surgical site hair removal.
Notes:
|
|
Notes on Session:
|
| |
ASCQR Calendar 4: (Under Development) Encouraged for continued
development |
|
|
|
Programs Under Consideration: Ambulatory Surgical Centers Quality
Reporting Program
|
|
Lead Discussant(s): Amanda Stefancyk Oberlies, Jack Fowler |
|
- O/ASPECS Overall Facility Rating (MUC ID:
X3702)
Description: Survey Question: Using any number from 0
10 10, where 0 is the worst facility possible and 10 is the best
facility possible, what number would you use to rate this facility?
Notes:
- O/ASPECS Recommend (MUC ID: X3703)
Description:
Survey question: Would you recommend this facility to your friends and
family? Response options: Definately no, Probably no, Probably yes,
Definately yes.
Notes:
- O/ASPECS About Facility and Staff (MUC ID:
X3698)
Description: Multi-item measure: P1: "When you arrived
at this facility on the day of your procedure, did the check-in process
run smoothly?" P2: "Was the facility clean?" P3: "Were the clerks and
receptionists at the facility as helpful as you thought they should be?"
P4: "Did the clerks and receptionists at the facility treat you with
courtesy and respect?" P5: "Did the doctors, nurses and other staff
treat you with courtesy and respect?" P6: "Did the doctors, nurses and
other staff make sure you were as comfortable as possible?"
Notes:
- O/ASPECS Communication (MUC ID: X3699)
Description:
Multi-item measure: P1: “Did your doctor or anyone from the facility
give you all the information you needed about your procedure?” P2: “Did
your doctor or anyone from the facility give you easy to understand
instructions about getting ready for your procedure?” P3: “Did the
doctors, nurses and other staff explain things about your procedure in a
way that was easy for you to understand?” P4 “Did your doctor or anyone
from the facility explain the process of giving anesthesia in a way that
was easy to understand? P5: “Did your doctor or anyone from the
facility explain the possible side effects of the anesthesia in a way
that was easy to understand?
Notes:
- O/ASPECS Discharge and Recovery (MUC ID:
X3697)
Description: Multi-item measure: P1: “Discharge
instructions include things like symptoms you should watch out for after
your procedure, instructions about your medicines, and home care. Before
you left the facility, did you receive written discharge instructions?”
P2: “Did your doctor or anyone from the facility prepare you for what
to expect during your recovery?” P3: “Ways to control pain can include
prescription medicine, over-the-counter pain relievers or ice packs, for
example. Did your doctor or anyone from the facility give you
information about what to do if you had pain as a result of your
procedure” (of those that had pain as a result of the procedure). P4:
“Before you left, did your doctor or anyone from the facility give you
information about what to do if you had nausea or vomiting” (of those
that had either nausea or vomiting as a result of either your
procedure or anesthesia). P5: “Before you left, did your doctor or
anyone from the facility give you information about what to do if you
had bleeding as a result of your procedure” (of those that had bleeding
as a result of the procedure). P6: “Possible signs of infection
include fever, swelling, heat, drainage or redness. Before you left, did
your doctor or anyone from the facility give you information about what
to do if you had possible signs of infection (of those having signs of
infection as a result of the procedure).
Notes:
|
|
Notes on Session:
|
| 10:45 am |
Opportunity for Public Comment |
|
|
| 11:00 am |
Break |
|
|
| 11:15 pm |
Measures Under Consideration for Medicare Shared Savings
Program |
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|
| |
MSSP Calendar 1: Support |
|
|
|
Programs Under Consideration: Medicare Shared Savings Program
|
|
Lead Discussant(s): Michael Phelan, Jamie Brooks Robertson |
|
- Perioperative Anti-platelet Therapy for Patients undergoing
Carotid Endarterectomy (MUC ID: E0465)
Description:
Percentage of patients undergoing carotid endarterectomy (CEA) who are
taking an anti-platelet agent (aspirin or clopidogrel or equivalent such
as aggrenox/tiglacor etc) within 48 hours prior to surgery and are
prescribed this medication at hospital discharge following surgery.
[Note: Description is for update to NQF endorsed measure and differs
from specifications provided in QPS]
Notes:
- Thorax CT: Use of Contrast Material (MUC ID:
E0513)
Description: This measure calculates the ratio of
thorax studies that are performed with and without contrast out of all
thorax studies performed (those with contrast, those without contrast,
and those with both). The measure is calculated based on a one year
window of claims data.
Notes:
- In-hospital mortality following elective open repair of AAAs
(MUC ID: E1523)
Description: Percentage of asymptomatic
patients undergoing open repair of abdominal aortic aneurysms (AAA) who
die while in hospital. This measure is proposed for both hospitals and
individual providers.
Notes:
- Payment-Standardized Medicare Spending Per Beneficiary (MSPB)
(MUC ID: E2158)
Description: The MSPB Measure assesses the
cost of services performed by hospitals and other healthcare providers
during an MSPB hospitalization episode, which comprises the period
immediately prior to, during, and following a patient’s hospital stay.
Beneficiary populations eligible for the MSPB calculation include
Medicare beneficiaries enrolled in Medicare Parts A and B who were
discharged from short-term acute hospitals during the period of
performance.[Note: Description differs from older version of measure
listed on QPS.]
Notes:
|
|
Notes on Session:
|
| |
MSSP Calendar 2: Conditional support pending resolution of data
concerns |
|
|
|
Programs Under Consideration: Medicare Shared Savings Program
|
|
Lead Discussant(s): Daniel Pollock, Mitchell Levy |
|
- National Healthcare Safety Network (NHSN) Catheter-associated
Urinary Tract Infection (CAUTI) Outcome (MUC ID:
S0138)
Description: CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary
indwelling catheters inserted, removing indwelling catheters at the
earliest possible time, securing catheters to the patient´s leg to avoid
bladder and urethral trauma, keeping the urine collection bag below the
level of the bladder, and utilizing aseptic technique for urinary
catheter insertion. These efforts will result in decreased morbidity and
mortality and reduce healthcare costs. Use of this measure to track
CAUTIs through a nationalized standard for HAI monitoring, leads to
improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts.
Notes:
- National Healthcare Safety Network (NHSN) Central line-associated
Bloodstream Infection (CLABSI) Outcome (MUC ID:
S0139)
Description: CLABSI can be minimized through proper
management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of lines
are recommended. These efforts result in decreased morbidity and
mortality and reduced healthcare costs.
Notes:
|
|
Notes on Session:
|
| |
MSSP Calendar 3: Conditional Support pending NQF review and
endorsement |
|
|
|
Programs Under Consideration: Medicare Shared Savings Program
|
|
Lead Discussant(s): Richard Bankowitz, Helen Haskell |
|
- Proportion of patients sustaining a bladder injury at the time of
any pelvic organ prolapse repair (MUC ID:
X3743)
Description: Percentage of patients undergoing any
surgery to repair pelvic organ prolapse who sustains an injury to the
bladder recognized either during or within 1 month after surgery
Notes:
- Proportion of patients sustaining a major viscus injury at the
time of any pelvic organ prolapse repair (MUC ID:
X3744)
Description: Percentage of patients undergoing surgical
repair of pelvic organ prolapse that is complicated by perforation of a
major viscous at the time of index surgery that is recognized
intraoperative or within 1 month after surgery
Notes:
- Proportion of patients sustaining a ureter injury at the time of
any pelvic organ prolapse repair (MUC ID:
X3813)
Description: Percentage of patients undergoing a pelvic
organ prolapse repair who sustain an injury to the ureter recognized
either during or within 1 month after surgery
Notes:
- Performing cystoscopy at the time of hysterectomy for pelvic
organ prolapse to detect lower urinary tract injury (MUC ID:
X3752)
Description: Percentage of patients who undergo
cystoscopy to evaluate for lower urinary tract injury at the time of
hysterectomy for pelvic organ prolapse.
Notes:
|
|
Notes on Session:
|
| |
MSSP Calendar 4: Conditional Support pending resubmission to NQF for
endorsement review |
|
|
|
Programs Under Consideration: Medicare Shared Savings Program
|
|
Lead Discussant(s): Shekar Mehta, Dana Alexander |
|
- MRI Lumbar Spine for Low Back Pain (MUC ID:
E0514)
Description: This measure calculates the percentage of
MRI of the Lumbar Spine studies with a diagnosis of low back pain on the
imaging claim and for which the patient did not have prior claims-based
evidence of antecedent conservative therapy. Antecedent conservative
therapy may include (see subsequent details for codes): 1. Claim(s) for
physical therapy in the 60 days preceding the Lumbar Spine MRI. 2.
Claim(s) for chiropractic evaluation and manipulative treatment in the
60 days preceding the Lumbar Spine MRI. 3. Claim(s) for evaluation and
management in the period >28 days and <60 days preceding the
Lumbar Spine MRI.
Notes:
|
|
Notes on Session:
|
| |
MSSP Calendar 5: Do Not Support |
|
|
|
Programs Under Consideration: Medicare Shared Savings Program
|
|
Lead Discussant(s): Karen Fields, Andrea Benin |
|
- Performing an intraoperative rectal examination at the time of
prolapse repair (MUC ID: X3740)
Description: Percentage of
patients having a documented rectal examination at the time of surgery
for repair of apical and posterior prolapse.
Notes:
|
|
Notes on Session:
|
| |
MSSP Calendar 6: (Under Development) Encouraged for continued
development |
|
|
|
Programs Under Consideration: Medicare Shared Savings Program
|
|
Lead Discussant(s): Wei Ying, David Engler |
|
- Door to puncture time for endovascular stroke treatment (MUC
ID: X3747)
Description: Door to puncture time less than 2
hours for patients undergoing endovascular stroke treatment
Notes:
- Prevention of Post-Operative Nausea and Vomiting (PONV) –
Combination (MUC ID: X3806)
Description: Percentage of
patients, aged 18 years and older, who undergo a procedure under an
inhalational general anesthetic, AND who have three or more risk factors
for post-operative nausea and vomiting (PONV), who receive combination
therapy consisting of at least two prophylactic pharmacologic antiemetic
agents of different classes preoperatively or intraoperatively
Notes:
- Post-Anesthetic Transfer of Care: Use of Checklist or Protocol
for Direct Transfer of Care from Procedure Room to Intensive Care Unit
(ICU) (MUC ID: X3807)
Description: Percentage of patients,
regardless of age, who undergo a procedure under anesthesia and are
admitted to an Intensive Care Unit (ICU) directly from the anesthetizing
location, who have a documented use of a checklist or protocol for the
transfer of care from the responsible anesthesia practitioner to the
responsible ICU team or team member
Notes:
- Post-Anesthetic Transfer of Care Measure: Procedure Room to a
Post Anesthesia Care Unit (PACU) (MUC ID:
X3810)
Description: Percentage of patients who are under the
care of an anesthesia practitioner and are admitted to a PACU in which a
post-anesthetic formal transfer of care protocol or checklist which
includes the key transfer of care elements is utilized.
Notes:
|
|
Notes on Session:
|
| |
MSSP Calendar 7: (Under Development) Do not encourage further
consideration |
|
|
|
Programs Under Consideration: Medicare Shared Savings Program
|
|
Lead Discussant(s): Sean Morrison, Amanda Stefancyk Oberlies |
|
- Preoperative Use of Aspirin for Patients with Drug-Eluting
Coronary Stents (MUC ID: X3808)
Description: Percentage of
patients, aged 18 years and older with a pre-existing drug-eluting
coronary stent, who undergo a surgical or therapeutic procedure under
anesthesia, who receive aspirin 24 hours prior to surgical start time
Notes:
- Perioperative Temperature Management (MUC ID:
X3809)
Description: Percentage of patients, regardless of age,
who undergo surgical or therapeutic procedures under general or
neuraxial anesthesia of 60 minutes duration or longer for whom at least
one body temperature greater than or equal to 35.5 degrees Celsius (or
95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately
before or the 15 minutes immediately after anesthesia end time
Notes:
- Anesthesiology Smoking Abstinence (MUC ID:
X3811)
Description: The percentage of current smokers who
abstain from cigarettes prior to anesthesia on the day of elective
surgery or procedure.
Notes:
|
|
Notes on Session:
|
| 12:30 pm |
Lunch |
|
|
| 1:30 pm |
Measures Under Consideration for Hospital-Acquired Condition (HAC)
Reduction Program |
|
|
| |
HAC Calendar 1: Support |
|
|
|
Programs Under Consideration: Hospital-Acquired Condition (HAC)
Reduction Program
|
|
Lead Discussant(s): Helen Haskell, Mitchell Levy |
|
- National Healthcare Safety Network (NHSN) Catheter-associated
Urinary Tract Infection (CAUTI) Outcome (MUC ID:
S0138)
Description: CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary
indwelling catheters inserted, removing indwelling catheters at the
earliest possible time, securing catheters to the patient´s leg to avoid
bladder and urethral trauma, keeping the urine collection bag below the
level of the bladder, and utilizing aseptic technique for urinary
catheter insertion. These efforts will result in decreased morbidity and
mortality and reduce healthcare costs. Use of this measure to track
CAUTIs through a nationalized standard for HAI monitoring, leads to
improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts.
Notes:
- National Healthcare Safety Network (NHSN) Central line-associated
Bloodstream Infection (CLABSI) Outcome (MUC ID:
S0139)
Description: CLABSI can be minimized through proper
management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of lines
are recommended. These efforts result in decreased morbidity and
mortality and reduced healthcare costs.
Notes:
|
|
Notes on Session:
|
| 2:00 pm |
Measures Under Consideration for Inpatient Psychiatric Facility
Quality Reporting |
|
|
| |
IPFQR Calendar 1: Support |
|
|
|
Programs Under Consideration: Inpatient Psychiatric Facilities Quality
Reporting Program
|
|
Lead Discussant(s): Wei Ying, Frank Opelka, Dolores L. Mitchell |
|
- Transition Record with Specified Elements Received by Discharged
Patients (Discharges from an Inpatient Facility to Home/Self Care or Any
Other Site of Care) (MUC ID: E0647)
Description:
Percentage of patients, regardless of age, discharged from an inpatient
facility (e.g., hospital inpatient or observation, skilled nursing
facility, or rehabilitation facility) to home or any other site of care,
or their caregiver(s), who received a transition record (and with whom a
review of all included information was documented) at the time of
discharge including, at a minimum, all of the specified elements
Notes:
- TOB-3 Tobacco Use Treatment Provided or Offered at Discharge AND
TOB-3a Tobacco Use Treatment at Discharge (MUC ID:
E1656)
Description: The measure is reported as an overall rate
which includes all hospitalized patients 18 years of age an older to
whom tobacco use treatment was provided, or offered and refused, at the
time of hospital discharge, and a second rate, a subset of the first,
which includes only those patients who received tobacco use treatment at
discharge. Treatment at discharge includes a referral to outpatient
counseling and a prescription for one of the FDA-approved tobacco
cessation medications. TOB-3 Patients identified as tobacco product
users within the past 30 days who were referred to or refused
evidence-based outpatient counseling AND received or refused a
prescription for FDA-approved cessation medication upon discharge.
TOB-3a Patients who were referred to evidence-based outpatient
counseling AND received a prescription for FDA-approved cessation
medication upon discharge as well as those who were referred to
outpatient counseling and had reason for not receiving a prescription
for medication.[For reference, description of endorsed measure in QPS:
The measure is reported as an overall rate which includes all
hospitalized patients 18 years of age an older to whom tobacco use
treatment was provided, or offered and refused, at the time of hospital
discharge, and a second rate, a subset of the first, which includes only
those patients who received tobacco use treatment at discharge.
Treatment at discharge includes a referral to outpatient counseling and
a prescription for one of the FDA-approved tobacco cessation
medications. Refer to section 2a1.10 Stratification Details/Variables
for the rationale for the addition of the subset measure. These measures
are intended to be used as part of a set of 4 linked measures addressing
Tobacco Use (TOB-1 Tobacco Use Screening; TOB 2 Tobacco Use Treatment
Provided or Offered During the Hospital Stay; TOB-4 Tobacco Use:
Assessing Status After Discharge).]
Notes:
- SUB-2 Alcohol Use Brief Intervention Provided or Offered. SUB-2a
Alcohol Use Brief Intervention Received. (MUC ID:
E1663)
Description: The measure is reported as an overall rate
which includes all hospitalized patients 18 years of age and older to
whom a brief intervention was provided, or offered and refused, and a
second rate, a subset of the first, which includes only those patients
who received a brief intervention. The Provided or Offered rate (SUB-2),
describes patients who screened positive for unhealthy alcohol use who
received or refused a brief intervention during the hospital stay. The
Alcohol Use Brief Intervention (SUB-2a) rate describes only those who
received the brief intervention during the hospital stay. Those who
refused are not included.[For reference, additional description for
endorsed measure included in QPS: These measures are intended to be used
as part of a set of 4 linked measures addressing Substance Use (SUB-1
Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided
or Offered; SUB-3 Alcohol and Other Drug Use Disorder Treatment
Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use: Assessing
Status after Discharge).]
Notes:
|
|
Notes on Session:
|
| |
IPFQR Calendar 2: Conditional Support upon harmonization with
HBIPS-7 |
|
|
|
Programs Under Consideration: Inpatient Psychiatric Facilities Quality
Reporting Program
|
|
Lead Discussant(s): Karen Fields, Cristie Upshaw Travis |
|
- Timely Transmission of Transition Record (Discharges from an
Inpatient Facility to Home/Self Care or Any Other Site of Care) (MUC
ID: E0648)
Description: Percentage of patients, regardless of
age, discharged from an inpatient facility (e.g., hospital inpatient or
observation, skilled nursing facility, or rehabilitation facility) to
home or any other site of care for whom a transition record was
transmitted to the facility or primary physician or other health care
professional designated for follow-up care within 24 hours of discharge
Notes:
|
|
Notes on Session:
|
| 2:35 pm |
Break |
|
|
| 2:45 pm |
Measures Under Consideration for Medicare and Medicaid EHR
Incentive Program for Hospitals and CAHs (Meaningful Use) |
|
|
| |
MU Calendar 1: (Under Development) Encouraged for continued
development |
|
|
|
Programs Under Consideration: Medicare and Medicaid EHR Incentive
Program for Hospitals and Critical Access Hospitals (CAHs)
|
|
Lead Discussant(s): Ronald S. Walters, Martin Hatlie, Shekhar Mehta
|
|
- Hospital-Wide All-Cause Unplanned Readmission Hybrid eMeasure
(MUC ID: X3701)
Description: This eMeasure estimates the
hospital-level, risk-standardized rate of unplanned, all-cause
readmission after admission for any eligible condition within 30 days of
hospital discharge (RSRR). The eMeasure reports a single summary RSRR,
derived from the volume-weighted results of five different models, one
for each of the following specialty cohorts (grouped by discharge
condition categories or procedure categories): surgery/gynecology,
general medicine, cardiorespiratory, cardiovascular, and neurology. The
eMeasure also indicates the hospital standardized risk ratios (SRR) for
each of these five specialty cohorts. This eMeasure is a re-engineering
of measure 1789, the Hospital-Wide All-Cause Risk-Standardized
Readmission Measure developed for patients 65 years and older using
Medicare claims. This reengineered measure uses clinical data elements
from patients’ electronic health records for risk adjustment in addition
to claims data.
Notes:
- Perinatal Care Cesarean section (PC O2) Nulliparous women with a
term, singleton baby in vertex position delivered by cesarean section
(MUC ID: X1970)
Description: This measure assesses the
number of nulliparous women with a term, singleton baby in a vertex
position who are delivered by a cesarean section. PC O2 is also part of
a set of five nationally implemented measures that address perinatal
care (PC-01: Elective Delivery, PC-03: Antenatal Steroids, PC-04: Health
Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive
Breast Milk Feeding).
Notes:
- Adverse Drug Events: - Inappropriate Renal Dosing of
Anticoagulants (MUC ID: X3323)
Description: Percentage of
patient-drug days with administration of anticoagulants requiring renal
dosing with at least one error in renal dosing
Notes:
- Timely Evaluation of High-Risk Individuals in the Emergency
Department (MUC ID: X1234)
Description: Median time from
emergency department (ED) arrival to provider evaluation for individuals
triaged at the two highest levels based on a five-level triage system
(e.g., triaged as “immediate” or “emergent”).
Notes:
|
|
Notes on Session:
|
| 3:20 pm |
Opportunity for Public Comment |
|
|
| 3:35 pm |
Summary of Day |
|
|
| 3:50 pm |
Adjourn |
|
|
| Day 2 |
|
|
|
| 8:00 am |
Breakfast |
|
|
| 8:30 am |
Welcome, Review Meeting Objectives, and Pre-Rulemaking Approach |
|
Frank Opelka, Workgroup Chair; Ron Walters, Workgroup Co-Chair; Taroon
Amin, Senior Director, NQF
|
| 8:45 am |
Measures Under Consideration for Hospital Inpatient Quality
Reporting |
|
|
| |
IQR Calendar 1: Support |
|
|
|
Programs Under Consideration: Inpatient Quality Reporting Program
|
|
Lead Discussant(s): Brock Slabach, Helen Haskell |
|
- National Healthcare Safety Network (NHSN) Central line-associated
Bloodstream Infection (CLABSI) Outcome (MUC ID:
S0139)
Description: CLABSI can be minimized through proper
management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of lines
are recommended. These efforts result in decreased morbidity and
mortality and reduced healthcare costs.
Notes:
- National Healthcare Safety Network (NHSN) Catheter-associated
Urinary Tract Infection (CAUTI) Outcome (MUC ID:
S0138)
Description: CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary
indwelling catheters inserted, removing indwelling catheters at the
earliest possible time, securing catheters to the patient´s leg to avoid
bladder and urethral trauma, keeping the urine collection bag below the
level of the bladder, and utilizing aseptic technique for urinary
catheter insertion. These efforts will result in decreased morbidity and
mortality and reduce healthcare costs. Use of this measure to track
CAUTIs through a nationalized standard for HAI monitoring, leads to
improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts.
Notes:
- Hospital 30-day, all-cause, risk-standardized readmission rate
(RSRR) following pneumonia hospitalization (MUC ID:
E0506)
Description: The measure estimates a hospital-level
risk-standardized readmission rate (RSRR) for patients discharged from
the hospital with a principal diagnosis of pneumonia. The outcome is
defined as unplanned readmission for any cause within 30 days of the
discharge date for the index admission. A specified set of planned
readmissions do not count as readmissions. The target population is
patients 18 and over. CMS annually reports the measure for patients who
are 65 years or older and are either enrolled in fee-for-service (FFS)
Medicare and hospitalized in non-federal hospitals or are hospitalized
in Veterans Health Administration (VA) facilities.
Notes:
- Hospital 30-day, all-cause, risk-standardized mortality rate
(RSMR) following pneumonia hospitalization (MUC ID:
E0468)
Description: The measure estimates a hospital 30-day
risk-standardized mortality rate (RSMR), defined as death for any cause
within 30 days after the date of admission of the index admission, for
patients 18 and older discharged from the hospital with a principal
diagnosis of pneumonia. CMS annually reports the measure for patients
who are 65 years or older and are either enrolled in fee-for-service
(FFS) Medicare and hospitalized in non-federal hospitals or are
hospitalized in Veterans Health Administration (VA) facilities.
Notes:
- Cardiac Rehabilitation Patient Referral From an Inpatient Setting
(MUC ID: E0642)
Description: Percentage of patients
admitted to a hospital with a primary diagnosis of an acute myocardial
infarction or chronic stable angina or who during hospitalization have
undergone coronary artery bypass (CABG) surgery, a percutaneous coronary
intervention (PCI), cardiac valve surgery (CVS), or cardiac
transplantation who are referred to an early outpatient cardiac
rehabilitation/secondary prevention program.
Notes:
|
|
Notes on Session:
|
| |
IQR Calendar 2: Conditional support pending NQF review of the testing
data in a Medicare population and resolution of parsimony concerns with
measures currently in the IQR program |
|
|
|
Programs Under Consideration: Inpatient Quality Reporting Program
|
|
Lead Discussant(s): Dolores L. Mitchell, Jamie Brooks Robertson,
Shelley Fuld Nasso |
|
- Proportion of Patients Hospitalized with AMI that have a
Potentially Avoidable Complication (during the Index Stay or in the
30-day Post-Discharge Period) (MUC ID: E0704)
Description:
Percent of adult population aged 18 – 65 years who were admitted to a
hospital with acute myocardial infarction (AMI), were followed for
one-month after discharge, and had one or more potentially avoidable
complications (PACs). PACs may occur during the index stay or during the
30-day post discharge period. Define PACs during each time period as one
of three types: (A) PACs during the Index Stay (Hospitalization): (1)
PACs related to the anchor condition: The index stay is regarded as
having a PAC if during the index hospitalization the patient develops
one or more complications such as cardiac arrest, ventricular
fibrillation, cardiogenic shock, stroke, coma, acute post-hemorrhagic
anemia etc. that may result directly due to AMI or its management. (2)
PACs due to Comorbidities: The index stay is also regarded as having a
PAC if one or more of the patient’s controlled comorbid conditions is
exacerbated during the hospitalization (i.e. it was not present on
admission). Examples of these PACs are diabetic emergency with hypo- or
hyperglycemia, tracheostomy, mechanical ventilation, pneumonia, lung
complications gastritis, ulcer, GI hemorrhage etc. (3) PACs suggesting
Patient Safety Failures: The index stay is regarded as having a PAC if
there are one or more complications related to patient safety issues.
Examples of these PACs are septicemia, meningitis, other infections,
phlebitis, deep vein thrombosis, pulmonary embolism or any of the
CMS-defined hospital acquired conditions (HACs). (B) PACs during the
30-day post discharge period: (1) PACs related to the anchor condition:
Readmissions and emergency room visits during the 30-day post discharge
period after an AMI are considered as PACs if they are for angina, chest
pain, another AMI, stroke, coma, heart failure etc. (2) PACs due to
Comorbidities: Readmissions and emergency room visits during the 30-day
post discharge period are also considered PACs if they are due to an
exacerbation of one or more of the patient’s comorbid conditions, such
as a diabetic emergency with hypo- or hyperglycemia, pneumonia, lung
complications, tracheostomy, mechanical ventilation etc. (3) PACs
suggesting Patient Safety Failures: Readmissions or emergency room
visits during the 30-day post discharge period are considered PACs if
they are due to sepsis, infections, phlebitis, deep vein thrombosis, or
for any of the CMS-defined hospital acquired conditions (HACs).
Notes:
- Proportion of Patients Hospitalized with Pneumonia that have a
Potentially Avoidable Complication (during the Index Stay or in the
30-day Post-Discharge Period) (MUC ID: E0708)
Description:
Percent of adult population aged 18 – 65 years who were admitted to a
hospital with Pneumonia, were followed for one-month after discharge,
and had one or more potentially avoidable complications (PACs).[Note:
Additional information about measure description included for endorsed
measure in QPS.]
Notes:
- Proportion of Patients Hospitalized with Stroke that have a
Potentially Avoidable Complication (during the Index Stay or in the
30-day Post-Discharge Period) (MUC ID: E0705)
Description:
Percent of adult population aged 18 – 65 years who were admitted to a
hospital with stroke, were followed for one-month after discharge, and
had one or more potentially avoidable complications (PACs). PACs may
occur during the index stay or during the 30-day post discharge period.
Define PACs during each time period as one of three types: (A) PACs
during the Index Stay (Hospitalization): (1) PACs related to the anchor
condition: The index stay is regarded as having a PAC if during the
index hospitalization for stroke the patient develops one or more
complications such as hypertensive encephalopathy, malignant
hypertension, coma, anoxic brain damage, or respiratory failure etc.
that may result directly from stroke or its management. (2) PACs due to
Comorbidities: The index stay is also regarded as having a PAC if one or
more of the patient’s controlled comorbid conditions is exacerbated
during the hospitalization (i.e. it was not present on admission).
Examples of these PACs are diabetic emergency with hypo- or
hyperglycemia, pneumonia, lung complications, acute myocardial
infarction, gastritis, ulcer, GI hemorrhage etc. (3) PACs suggesting
Patient Safety Failures: The index stay is regarded as having a PAC if
there are one or more complications related to patient safety issues.
Examples of these PACs are septicemia, meningitis, other infections,
phlebitis, deep vein thrombosis, pulmonary embolism or any of the
CMS-defined hospital acquired conditions (HACs). (B) PACs during the
30-day post discharge period: (1) PACs related to the anchor condition:
Readmissions and emergency room visits during the 30-day post discharge
period after a stroke are considered as PACs if they are for
hypertensive encephalopathy, malignant hypertension, respiratory
failure, coma, anoxic brain damage etc. (2) PACs due to Comorbidities:
Readmissions and emergency room visits during the 30-day post discharge
period are also considered PACs if they are due to an exacerbation of
one or more of the patient’s comorbid conditions, such as a diabetic
emergency with hypo- or hyperglycemia, pneumonia, lung complications,
acute myocardial infarction, acute renal failure etc. (3) PACs
suggesting Patient Safety Failures: Readmissions or emergency room
visits during the 30-day post discharge period are considered PACs if
they are due to sepsis, infections, deep vein thrombosis, pulmonary
embolism, or for any of the CMS-defined hospital acquired conditions
(HACs).
Notes:
|
|
Notes on Session:
|
| _ |
IQR Calendar 3: Conditional support. This measure should be quickly
replaced with a measure assessing results of a survey of a culture of
patient safety |
|
|
|
Programs Under Consideration: Inpatient Quality Reporting Program
|
|
Lead Discussant(s): Shekhar Mehta, Cristie Travis |
|
- Participation in a Patient Safety Culture Survey (MUC ID:
X3689)
Description: Participation in a patient safety culture
survey involves a) What is the name of the survey? b) How frequently
is the survey administered? c) Which staff positions complete the
survey? d) Are survey results reported to a centralized location? e)
What is the survey response rate?
Notes:
|
|
Notes on Session:
|
| |
IQR Calendar 4: Conditional Support pending demonstration of
applicability at the facility level and resolution of the duplicative
nature of this measure with the falls and trauma component of PSI-90 |
|
|
|
Programs Under Consideration: Inpatient Quality Reporting Program
|
|
Lead Discussant(s): Martin Hatlie, Richard Bankowitz |
|
- Falls with injury (MUC ID: E0202)
Description: All
documented patient falls with an injury level of minor or greater on
eligible unit types in a calendar quarter. Reported as Injury falls per
1000 Patient Days. (Total number of injury falls / Patient days) X
1000 Measure focus is safety. Target population is adult acute care
inpatient and adult rehabilitation patients.
Notes:
- Patient fall rate (MUC ID: E0141)
Description: All
documented falls, with or without injury, experienced by patients on
eligible unit types in a calendar quarter. Reported as Total Falls per
1,000 Patient Days and Unassisted Falls per 1000 Patient Days. (Total
number of falls / Patient days) X 1000 Measure focus is safety.
Target population is adult acute care inpatient and adult rehabilitation
patients.
Notes:
|
|
Notes on Session:
|
| |
IQR Calendar 5: Conditional Support pending NQF review and
endorsement |
|
|
|
Programs Under Consideration: Inpatient Quality Reporting Program
|
|
Lead Discussant(s): David Engler, Karen Fields, Ronald Walters |
|
- Hospital 30-day, all-cause, unplanned risk-standardized days in
acute care following acute myocardial infarction (AMI) hospitalization
(MUC ID: X3728)
Description: This measure assesses days
spent in acute care after discharge from an acute care setting for an
acute myocardial infarction (AMI) hospitalization to provide a
patient-centered assessment of the post-discharge period. Acute care
utilization after discharge (return to the emergency department,
observation stay and readmission), for any reason, is disruptive to
patients and caregivers, costly to the healthcare system, and puts
patients at additional risk of hospital-acquired infections and
complications. Although some hospital returns are unavoidable, they may
also result from poor quality of care or inadequate transitional care.
When appropriate care transition processes are in place (for example,
patient is discharged to a suitable location, communication occurs
between clinicians, medications are correctly reconciled, timely
follow-up is arranged), fewer patients return to an acute care setting,
either for an emergency department (ED) visit, observation stay, or
hospital readmission during the 30 days post-discharge. Therefore, this
measure is intended to capture the quality of care transitions provided
to patients hospitalized with AMI by collectively measuring a set of
adverse outcomes that can occur post-discharge: ED visits, unplanned
observation stays, and unplanned readmissions at any time during the 30
days post-discharge. In order to aggregate all three events, we measure
each in terms of days of outcomes. Use of a day-count outcome generates
a clinically reasonable and natural weighting scheme such that events
that take more days (i.e. days rehospitalized) naturally carry more
weight than events taking fewer days (i.e. ED visits). That is, the
weight of each component of the composite is determined by its actual
impact and burden on patients, not by an arbitrary weighting scheme. We
then risk adjust the day count to account for age, gender and
comorbidity. The final reported outcome is risk-standardized by
subtracting the expected number of acute care days from the predicted
number. The risk-standardized days of acute care are multiplied by 100
to represent risk-standardized days of events per 100 admissions.
Notes:
- Hospital 30-day, all-cause, unplanned risk-standardized days in
acute care following heart failure hospitalization (MUC ID:
X3722)
Description: This measure assesses days spent in acute
care after discharge from an acute care setting for a heart failure
hospitalization to provide a patient-centered assessment of the
post-discharge period. Acute care utilization after discharge (return to
the emergency department, observation stay and readmission), for any
reason, is disruptive to patients and caregivers, costly to the
healthcare system, and puts patients at additional risk of
hospital-acquired infections and complications. Although some hospital
returns are unavoidable, they may also result from poor quality of care
or inadequate transitional care. When appropriate care transition
processes are in place (for example, patient is discharged to a suitable
location, communication occurs between clinicians, medications are
correctly reconciled, timely follow-up is arranged), fewer patients
return to an acute care setting, either for an emergency department (ED)
visit, observation stay, or hospital readmission during the 30 days
post-discharge. Therefore, this measure is intended to capture the
quality of care transitions provided to patients hospitalized with heart
failure by collectively measuring a set of adverse outcomes that can
occur post-discharge: ED visits, unplanned observation stays, and
unplanned readmissions at any time during the 30 days post-discharge. In
order to aggregate all three events, we measure each in terms of days of
outcomes. Use of a day-count outcome generates a clinically reasonable
and natural weighting scheme such that events that take more days (i.e.
days rehospitalized) naturally carry more weight than events taking
fewer days (i.e. ED visits). That is, the weight of each component of
the composite is determined by its actual impact and burden on patients,
not by an arbitrary weighting scheme. We then risk adjust the day count
to account for age, gender and comorbidity. The final reported outcome
is risk-standardized by subtracting the expected number of acute care
days from the predicted number. The risk-standardized days of acute care
are multiplied by 100 to represent risk-standardized days of events per
100 admissions.
Notes:
- Hospital 30-day, all-cause, unplanned risk-standardized days in
acute care following pneumonia hospitalization (MUC ID:
X3727)
Description: This measure assesses days spent in acute
care after discharge from an acute care setting for a pneumonia
hospitalization to provide a patient-centered assessment of the
post-discharge period. Acute care utilization after discharge (return to
the emergency department, observation stay and readmission), for any
reason, is disruptive to patients and caregivers, costly to the
healthcare system, and puts patients at additional risk of
hospital-acquired infections and complications. Although some hospital
returns are unavoidable, they may also result from poor quality of care
or inadequate transitional care. When appropriate care transition
processes are in place (for example, patient is discharged to a suitable
location, communication occurs between clinicians, medications are
correctly reconciled, timely follow-up is arranged), fewer patients
return to an acute care setting, either for an emergency department (ED)
visit, observation stay, or hospital readmission during the 30 days
post-discharge. Therefore, this measure is intended to capture the
quality of care transitions provided to patients hospitalized with
pneumonia by collectively measuring a set of adverse outcomes that can
occur post-discharge: ED visits, unplanned observation stays, and
unplanned readmissions at any time during the 30 days post-discharge. In
order to aggregate all three events, we measure each in terms of days of
outcomes. Use of a day-count outcome generates a clinically reasonable
and natural weighting scheme such that events that take more days (i.e.
days rehospitalized) naturally carry more weight than events taking
fewer days (i.e. ED visits). That is, the weight of each component of
the composite is determined by its actual impact and burden on patients,
not by an arbitrary weighting scheme. We then risk adjust the day count
to account for age, gender and comorbidity. The final reported outcome
is risk-standardized by subtracting the expected number of acute care
days from the predicted number. The risk-standardized days of acute care
are multiplied by 100 to represent risk-standardized days of events per
100 admissions.
Notes:
- Hospital-level, risk-standardized payment associated with an
episode of care for primary elective total hip and/or total knee
arthroplasty (THA/TKA) (MUC ID: X3620)
Description: This
measure estimates hospital-level, risk-standardized payments for a
primary elective total THA/TKA episode of care starting with inpatient
admission to a short term acute-care facility for Medicare
fee-for-service (FFS) patients who are 65 years of age or older.
Notes:
- Kidney/Urinary Tract Infection Clinical Episode-Based Payment
Measure (MUC ID: X0351)
Description: The Kidney/Urinary
Tract Infection Clinical Episode-Based Payment Measure constructs a
clinically coherent group of medical services that can be used to inform
providers about their resource use and effectiveness and establish a
standard for value-based incentive payments. Kidney/Urinary Tract
Infection episodes are defined as the set of services provided to treat,
manage, diagnose, and follow up on (including post-acute care) a patient
with a kidney/urinary tract infection hospital admission. The
Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure,
like the NQF-endorsed Medicare Spending Per Beneficiary (MSPB) measure,
assesses the cost of services initiated during an episode that spans the
period immediately prior to, during, and following a patient’s hospital
stay. In contrast to the MSPB measure, the Kidney/Urinary Tract
Infection Clinical Episode-Based Payment Measure includes Medicare
payments only for services that are clinically related to the
kidney/urinary tract infection treated during the index hospital stay.
The measure sums the Medicare payment amounts for clinically related
Part A and Part B services provided during this timeframe and attributes
them to the hospital at which the index hospital stay occurred or to the
physician group primarily responsible for the beneficiary’s care during
the index hospital stay. Medicare payments included in this
episode-based measure are standardized and risk-adjusted.
Notes:
- Spine Fusion/ Refusion Clinical Episode-Based Payment Measure
(MUC ID: X0353)
Description: The Spine Fusion/Refusion
Clinical Episode-Based Payment Measure constructs a clinically coherent
group of medical services that can be used to inform providers about
their resource use and effectiveness and establish a standard for
value-based incentive payments. Spine Fusion/Refusion episodes are
defined as the set of services provided to treat, manage, diagnose, and
follow up on (including post-acute care) a patient who receives a spine
fusion/refusion. The Spine Fusion/Refusion Clinical Episode-Based
Payment Measure, like the NQF-endorsed Medicare Spending Per Beneficiary
(MSPB) measure, assesses the cost of services initiated during an
episode that spans the period immediately prior to, during, and
following a patient’s hospital stay. In contrast to the MSPB measure,
the Spine Fusion/Refusion Clinical Episode-Based Payment Measure
includes Medicare payments only for services that are clinically related
to the spine fusion/refusion performed during the index hospital stay.
The measure sums the Medicare payment amounts for clinically related
Part A and Part B services provided during this timeframe and attributes
them to the hospital at which the index hospital stay occurred or to the
physician group primarily responsible for the beneficiary’s care during
the index hospital stay. Medicare payments included in this
episode-based measure are standardized and risk-adjusted.
Notes:
- Cellulitis Clinical Episode-Based Payment Measure (MUC ID:
X0354)
Description: The Cellulitis Clinical Episode-Based
Payment Measure constructs a clinically coherent group of medical
services that can be used to inform providers about their resource use
and effectiveness and establish a standard for value-based incentive
payments. Cellulitis episodes are defined as the set of services
provided to treat, manage, diagnose, and follow up on (including
post-acute care) a patient with a cellulitis hospital admission. The
Cellulitis Clinical Episode-Based Payment Measure, like the NQF-endorsed
Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of
services initiated during an episode that spans the period immediately
prior to, during, and following a patient’s hospital stay. In contrast
to the MSPB measure, the Cellulitis Clinical Episode-Based Payment
Measure includes Medicare payments only for services that are clinically
related to the cellulitis treated during the index hospital stay. The
measure sums the Medicare payment amounts for clinically related Part A
and Part B services provided during this timeframe and attributes them
to the hospital at which the index hospital stay occurred or to the
physician group primarily responsible for the beneficiary’s care during
the index hospital stay. Medicare payments included in this
episode-based measure are standardized and risk-adjusted.
Notes:
- Gastrointestinal Hemorrhage Clinical Episode-Based Payment
Measure (MUC ID: X0355)
Description: The Gastrointestinal
Hemorrhage Clinical Episode-Based Payment Measure constructs a
clinically coherent group of medical services that can be used to inform
providers about their resource use and effectiveness and establish a
standard for value-based incentive payments. Gastrointestinal Hemorrhage
episodes are defined as the set of services provided to treat, manage,
diagnose, and follow up on (including post-acute care) a patient with a
gastrointestinal hemorrhage hospital admission. The Gastrointestinal
Hemorrhage Clinical Episode-Based Payment Measure, like the NQF-endorsed
Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of
services initiated during an episode that spans the period immediately
prior to, during, and following a patient’s hospital stay. In contrast
to the MSPB measure, the Gastrointestinal Hemorrhage Clinical
Episode-Based Payment Measure includes Medicare payments only for
services that are clinically related to the gastrointestinal hemorrhage
treated during the index hospital stay. The measure sums the Medicare
payment amounts for clinically related Part A and Part B services
provided during this timeframe and attributes them to the hospital at
which the index hospital stay occurred or to the physician group
primarily responsible for the beneficiary’s care during the index
hospital stay. Medicare payments included in this episode-based measure
are standardized and risk-adjusted.
Notes:
|
|
Notes on Session:
|
| |
IQR Calendar 6: Do Not Support |
|
|
|
Programs Under Consideration: Inpatient Quality Reporting Program
|
|
Lead Discussant(s): Nancy Foster, Dana Alexander |
|
- Skill mix (Registered Nurse [RN], Licensed Vocational/Practical
Nurse [LVN/LPN], unlicensed assistive personnel [UAP], and contract)
(MUC ID: E0204)
Description: NSC-12.1 - Percentage of
total productive nursing hours worked by RN (employee and contract) with
direct patient care responsibilities by hospital unit. NSC-12.2 -
Percentage of total productive nursing hours worked by LPN/LVN (employee
and contract) with direct patient care responsibilities by hospital
unit. NSC-12.3 - Percentage of total productive nursing hours worked
by UAP (employee and contract) with direct patient care responsibilities
by hospital unit. NSC-12.4 - Percentage of total productive nursing
hours worked by contract or agency staff (RN, LPN/LVN, and UAP) with
direct patient care responsibilities by hospital unit. Note that the
skill mix of the nursing staff (NSC-12.1, NSC-12.2, and NSC-12.3)
represent the proportions of total productive nursing hours by each type
of nursing staff (RN, LPN/LVN, and UAP); NSC-12.4 is a separate rate.
Measure focus is structure of care quality in acute care hospital units.
Notes:
- Nursing Hours per Patient Day (MUC ID:
E0205)
Description: NSC-13.1 (RN hours per patient day) – The
number of productive hours worked by RNs with direct patient care
responsibilities per patient day for each in-patient unit in a calendar
month. NSC-13.2 (Total nursing care hours per patient day) – The
number of productive hours worked by nursing staff (RN,LPN/LVN, and UAP)
with direct patient care responsibilities per patient day for each
in-patient unit in a calendar month. Measure focus is structure of
care quality in acute care hospital units.
Notes:
|
|
Notes on Session:
|
| |
IQR Calendar 7: (Under Development) Encouraged for continued
development |
|
|
|
Programs Under Consideration: Inpatient Quality Reporting Program
|
|
Lead Discussant(s): Richard Bankowitz, Jack Fowler, Jr., Andrea
Benin |
|
- Adverse Drug Events: - Inappropriate Renal Dosing of
Anticoagulants (MUC ID: X3323)
Description: Percentage of
patient-drug days with administration of anticoagulants requiring renal
dosing with at least one error in renal dosing
Notes:
- Hospital-Wide All-Cause Unplanned Readmission Hybrid eMeasure
(MUC ID: X3701)
Description: This eMeasure estimates the
hospital-level, risk-standardized rate of unplanned, all-cause
readmission after admission for any eligible condition within 30 days of
hospital discharge (RSRR). The eMeasure reports a single summary RSRR,
derived from the volume-weighted results of five different models, one
for each of the following specialty cohorts (grouped by discharge
condition categories or procedure categories): surgery/gynecology,
general medicine, cardiorespiratory, cardiovascular, and neurology. The
eMeasure also indicates the hospital standardized risk ratios (SRR) for
each of these five specialty cohorts. This eMeasure is a re-engineering
of measure 1789, the Hospital-Wide All-Cause Risk-Standardized
Readmission Measure developed for patients 65 years and older using
Medicare claims. This reengineered measure uses clinical data elements
from patients’ electronic health records for risk adjustment in addition
to claims data.
Notes:
- Timely Evaluation of High-Risk Individuals in the Emergency
Department (MUC ID: X1234)
Description: Median time from
emergency department (ED) arrival to provider evaluation for individuals
triaged at the two highest levels based on a five-level triage system
(e.g., triaged as “immediate” or “emergent”).
Notes:
- Perinatal Care Cesarean section (PC O2) Nulliparous women with a
term, singleton baby in vertex position delivered by cesarean section
(MUC ID: X1970)
Description: This measure assesses the
number of nulliparous women with a term, singleton baby in a vertex
position who are delivered by a cesarean section. PC O2 is also part of
a set of five nationally implemented measures that address perinatal
care (PC-01: Elective Delivery, PC-03: Antenatal Steroids, PC-04: Health
Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive
Breast Milk Feeding).
Notes:
|
|
Notes on Session:
|
| 10:35 |
Public Comment on IQR Consent Calendars |
|
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| 10:45 am |
Break |
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| 11:00 am |
Measures Under Consideration for Hospital Value-based Purchasing
(VBP) Program |
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VBP Calendar 1: Support |
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Programs Under Consideration:
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Lead Discussant(s): Michael P. Phelan, Mitchell Levy |
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- Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate
(RSMR) following Chronic Obstructive Pulmonary Disease (COPD)
Hospitalization (MUC ID: E1893)
Description: The measure
estimates a hospital-level risk-standardized mortality rate (RSMR),
defined as death from any cause within 30 days after the index admission
date, for patients 40 and older discharged from the hospital with either
a principal diagnosis of COPD or a principal diagnosis of respiratory
failure with a secondary diagnosis of acute exacerbation of COPD. CMS
will annually report the measure for patients who are 65 years or older,
enrolled in fee-for-service (FFS) Medicare, and hospitalized in
non-federal hospitals.
Notes:
- Hospital 30-day, all-cause, risk-standardized mortality rate
(RSMR) following pneumonia hospitalization (MUC ID:
E0468)
Description: The measure estimates a hospital 30-day
risk-standardized mortality rate (RSMR), defined as death for any cause
within 30 days after the date of admission of the index admission, for
patients 18 and older discharged from the hospital with a principal
diagnosis of pneumonia. CMS annually reports the measure for patients
who are 65 years or older and are either enrolled in fee-for-service
(FFS) Medicare and hospitalized in non-federal hospitals or are
hospitalized in Veterans Health Administration (VA) facilities.
Notes:
- National Healthcare Safety Network (NHSN) Central line-associated
Bloodstream Infection (CLABSI) Outcome (MUC ID:
S0139)
Description: CLABSI can be minimized through proper
management of the central line. Efforts to improve central line
insertion and maintenance practices, with early discontinuance of lines
are recommended. These efforts result in decreased morbidity and
mortality and reduced healthcare costs.
Notes:
- National Healthcare Safety Network (NHSN) Catheter-associated
Urinary Tract Infection (CAUTI) Outcome (MUC ID:
S0138)
Description: CAUTI can be minimized by a collection of
prevention efforts. These include reducing the number of unnecessary
indwelling catheters inserted, removing indwelling catheters at the
earliest possible time, securing catheters to the patient´s leg to avoid
bladder and urethral trauma, keeping the urine collection bag below the
level of the bladder, and utilizing aseptic technique for urinary
catheter insertion. These efforts will result in decreased morbidity and
mortality and reduce healthcare costs. Use of this measure to track
CAUTIs through a nationalized standard for HAI monitoring, leads to
improved patient outcomes and provides a mechanism for identifying
improvements and quality efforts.
Notes:
- Death among surgical inpatients with serious, treatable
complications (PSI 4) (MUC ID: E0351)
Description:
Percentage of cases having developed specified complications of care
with an in-hospital death.
Notes:
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Notes on Session:
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| 12:20 pm |
Public Comment on VBP Consent Calendars |
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| 12:30 pm |
Lunch |
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| 1:30 pm |
Measures Under Consideration for PPS-Exempt Cancer Hospital Quality
Reporting Program |
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PCHQR Calendar 1: Support |
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Programs Under Consideration: PPS-Exempt Cancer Hospital Quality
Reporting Program
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Lead Discussant(s): Shelly Nasso R. Sean Morrison Louise Y. Probst
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- At least 12 regional lymph nodes are removed and pathologically
examined for resected colon cancer (MUC ID:
E0225)
Description: Percentage of patients >18yrs of age,
who have primary colon tumors (epithelial malignancies only),
experiencing their first diagnosis, at AJCC stage I, II or III who have
at least 12 regional lymph nodes removed and pathologically examined
for resected colon cancer. 1b.1. Developer Rationale: Improved survival
for patients
Notes:
- Post breast conservation surgery irradiation (MUC ID:
E0219)
Description: Percentage of female patients, age 18-69,
who have their first diagnosis of breast cancer (epithelial malignancy),
at AJCC stage I, II, or III, receiving breast conserving surgery who
receive radiation therapy within 1 year (365 days) of diagnosis.
Notes:
- Needle biopsy to establish diagnosis of cancer precedes surgical
excision/resection (MUC ID: E0221)
Description: Percentage
of patients presenting with AJCC Stage Group 0, I, II, or III disease,
who undergo surgical excision/resection of a primary breast tumor who
undergo a needle biopsy to establish diagnosis of cancer preceding
surgical excision/resection.
Notes:
- Hospice and Palliative Care – Treatment Preferences (MUC ID:
E1641)
Description: Percentage of patients with chart
documentation of preferences for life sustaining treatments.
Notes:
- National Healthcare Safety Network (NHSN) Facility-wide Inpatient
Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA)
Bacteremia Outcome Measure (MUC ID: E1716)
Description:
Standardized infection ratio (SIR) of hospital-onset unique blood source
MRSA Laboratory-identified events (LabID events) among all inpatients in
the facility
Notes:
- National Healthcare Safety Network (NHSN) Facility-wide Inpatient
Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure
(MUC ID: E1717)
Description: Standardized infection ratio
(SIR) of hospital-onset CDI Laboratory-identified events (LabID events)
among all inpatients in the facility, excluding well-baby nurseries and
neonatal intensive care units (NICUs)
Notes:
- Influenza Immunization (MUC ID: E1659)
Description:
Inpatients age 6 months and older discharged during October, November,
December, January, February or March who are screened for influenza
vaccine status and vaccinated prior to discharge if indicated.
Notes:
- Influenza vaccination coverage among healthcare personnel (HCP)
(MUC ID: E0431)
Description: Percentage of healthcare
personnel (HCP) who receive the influenza vaccination.
Notes:
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Notes on Session:
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PCHQR Calendar 2: (Under Development) Encourage continued
development |
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Programs Under Consideration: PPS-Exempt Cancer Hospital Quality
Reporting Program
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Lead Discussant(s): David Engler, Cristie Upshaw Travis, Shekhar
Mehta |
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- 30 Day Unplanned Readmissions for Cancer Patients (MUC ID:
X3629)
Description: Number of hospital-specific 30-day
unscheduled and potentially avoidable readmissions following
hospitalization among diagnosed malignant cancer patients
Notes:
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Notes on Session:
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| 2:20 |
Public Comment on PCHQR Consent Calendars |
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| 2:30 pm |
Measures Under Consideration for Hospital Readmission Reduction
Program |
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HRRP Calendar 1: Support |
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Programs Under Consideration: Hospital Readmission Reduction Program
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Lead Discussant(s): Kelly Trautner David Engler |
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- Hospital 30-day, all-cause, risk-standardized readmission rate
(RSRR) following pneumonia hospitalization (MUC ID:
E0506)
Description: The measure estimates a hospital-level
risk-standardized readmission rate (RSRR) for patients discharged from
the hospital with a principal diagnosis of pneumonia. The outcome is
defined as unplanned readmission for any cause within 30 days of the
discharge date for the index admission. A specified set of planned
readmissions do not count as readmissions. The target population is
patients 18 and over. CMS annually reports the measure for patients who
are 65 years or older and are either enrolled in fee-for-service (FFS)
Medicare and hospitalized in non-federal hospitals or are hospitalized
in Veterans Health Administration (VA) facilities.
Notes:
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Notes on Session:
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| 3:00pm |
Public Comment on HRRP Consent Calendars |
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| 3:15 pm |
Feedback on Process Improvements |
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| 3:45 pm |
Summary of Day |
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| 4:00 pm |
Adjourn |
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