Measure Applications Partnership
Hospital Workgroup Discussion Guide

Notes for Measure Deliberations
Version Number: 8.2
Meeting Date: December 8-9, 2016

Full Agenda

Day 1  
8:30 am   Breakfast
9:00 am   Welcome, Introductions, Disclosures of Interest, and Review of Meeting Objectives
Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair Ronald Walters, MAP Hospital Workgroup Co-Chair Melissa Mariñelarena, Senior Director, NQF Ann Hammersmith, General Counsel, NQF

9:15 am   CMS Opening Remarks
Pierre Yong, Director, Quality Measurement and Value-Based Incentives Group, CMS

9:45 am   NQF Strategic Plan
Helen Burstin, Chief Scientific Officer, NQF

10:00 am   Overview of Pre-Rulemaking Approach
Melissa Mariñelarena, Senior Director, NQF Kate McQueston, Project Manager, NQF

10:15 am   Overview of the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) Program
10:25 am   Opportunity for Public Comment on Measures Under Consideration for End-Stage Renal Disease Quality Incentive Program (ESRD QIP)
10:35 am   Pre-Rulemaking Input Measure Sets on End-Stage Renal Disease Quality Incentive Program (ESRD QIP)—Consent Calendar 1
Allen Nissenson, Kidney Care Partners Elizabeth Evans, Individual Subject Matter Expert
Programs under consideration:
  1. Hemodialysis Vascular Access: Long-term Catheter Rate (MUC ID: MUC16-309)
    • Description: Percentage of adult hemodialysis patient-months using a catheter continuously for three months or longer for vascular access.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is intended to replace the existing vascular access type measure in the ESRD QIP. The measure is currently under review by the Renal Standing Committee. The Standing Committee and CSAC recommended the measure for endorsement
      • Impact on quality of care for patients:This measure provides dialysis patients with information about the long-term use of catheters for vascular access.
    • Preliminary analysis result: Support for Rulemaking
    • Notes:





  2. Hemodialysis Vascular Access: Standardized Fistula Rate (MUC ID: MUC16-308)
    • Description: Adjusted percentage of adult hemodialysis patient-months using an autogenous arteriovenous fistula (AVF) as the sole means of vascular access.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is intended to replace the existing vascular access type measure in the ESRD QIP. The measure is currently under review by the Renal Standing Committee. The Standing Committee and CSAC recommended the measure for endorsement.
      • Impact on quality of care for patients:This measure provides dialysis patients with information about the use of autogenous arteriovenous fistula (AVF) as the sole means of vascular access.
    • Preliminary analysis result: Support for Rulemaking
    • Notes:





  3. Standardized Transfusion Ratio for Dialysis Facilities (MUC ID: MUC16-305)
    • Description: The risk adjusted facility level transfusion ratio “STrR” is specified for all adult dialysis patients. It is a ratio of the number of eligible red blood cell transfusion events observed in patients dialyzing at a facility, to the number of eligible transfusion events that would be expected under a national norm, after accounting for the patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure has undergone substantial changes but details of the changes to the measure are not provided. The measure is currently under review by the Renal Standing Committee. The Standing Committee and CSAC recommended the measure for endorsement.
      • Impact on quality of care for patients:This measure encourages dialysis facilities to avoid blood transfusions when managing patients with anemia.
    • Preliminary analysis result: Support for Rulemaking
    • Notes:





11:15 am   Break
11:30 am   Overview of the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
11:40 am   Opportunity for Public Comment on Measures Under Consideration for PCHQR
11:50 am   Pre-Rulemaking Input for Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR)—Consent Calendar 2
R. Sean Morrison, Individual Subject Matter Expert Sarah Nolan, Service Employees International Union Heather Lewis, Geisinger Health System
Programs under consideration: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program
  1. PRO utilization in in non-metastatic prostate cancer patients (MUC ID: MUC16-393)
    • Description: Use of a validated patient-reported outcome (PRO) instrument to measure functional status in adult, non-metastatic prostate cancer patients during the 12-month measurement period.
    • Preliminary analysis summary
      • Contribution to program measure set:It is unclear if the value of this measure to patients/consumers outweighs the burden of implementation. There is limited information regarding how the measure can be operationalized and the measure is not fully specified and tested.
      • Impact on quality of care for patients:This measure would encourage facilities measure functional status in adult patients with non-metastatic prostate cancer using a validated survey instrument.
    • Preliminary analysis result: Do Not Support for Rulemaking
    • Notes:





  2. Proportion of patients who died from cancer admitted to hospice for less than 3 days (MUC ID: MUC16-274)
    • Description: Proportion of patients who died from cancer admitted to hospice for less than 3 days
    • Preliminary analysis summary
      • Contribution to program measure set:The measure is not specified and tested at the facility level in the hospital setting. The Palliative Care and End-of-Life Standing Committee, CSAC and the NQF Executive Committee recommended the measure for endorsement at the group/clinician level in the ambulatory care setting. The measure should be specified, tested and NQF endorsed at the facility level in the hospital setting for the PPS-Exempt Cancer Hospital Quality Reporting Program.
      • Impact on quality of care for patients:This measure provides the proportion of patients who died from cancer and were admitted to hospice for less than 3 days.
    • Preliminary analysis result: Refine and Resubmit
    • Notes:





  3. Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life (MUC ID: MUC16-273)
    • Description: Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life
    • Preliminary analysis summary
      • Contribution to program measure set:The measure has not been specified and tested at the facility level in the hospital setting. The Palliative Care and End-of-Life Standing Committee, CSAC and the NQF Executive Committee recommended the measure for endorsement at the group/clinician level in the ambulatory care setting. The measure should be specified, tested and NQF endorsed at the facility level in the hospital setting for the PPS-Exempt Cancer Hospital Quality Reporting Program.
      • Impact on quality of care for patients:This measure provides the proportion of patients who died from cancer and were admitted to the ICU in the last 30 days of life.
    • Preliminary analysis result: Support for Rulemaking
    • Notes:





  4. Proportion of patients who died from cancer not admitted to hospice (MUC ID: MUC16-275)
    • Description: Proportion of patients who died from cancer not admitted to hospice
    • Preliminary analysis summary
      • Contribution to program measure set:The measure is not specified and tested at the facility level in the hospital setting. The Palliative Care and End-of-Life Standing Committee, CSAC and the NQF Executive Committee recommended the measure for endorsement at the group/clinician level in the ambulatory care setting. The measure should be specified, tested and NQF endorsed at the facility level in the hospital setting for the PPS-Exempt Cancer Hospital Quality Reporting Program.
      • Impact on quality of care for patients:This measure provides the proportion of patients who died from cancer and were not admitted to hospice.
    • Preliminary analysis result: Refine and Resubmit for Rulemaking
    • Notes:





  5. Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life (MUC ID: MUC16-271)
    • Description: Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life
    • Preliminary analysis summary
      • Contribution to program measure set:The measure has not been specified and tested at the facility level in the hospital setting. The Palliative Care and End-of-Life Standing Committee, CSAC and the NQF Executive Committee recommended the measure for endorsement at the group/clinician level in the ambulatory care setting. The measure should be specified, tested and NQF endorsed at the facility level in the hospital setting for the PPS-Exempt Cancer Hospital Quality Reporting Program.
      • Impact on quality of care for patients:The measure provides patients with the proportion of cancer patients who receive chemotherapy in the last 14 days of life.
    • Preliminary analysis result: Refine and Resubmit
    • Notes:





12:30 pm   Lunch
1:00 pm   Overview of the Ambulatory Surgery Center Quality Reporting (ASCQR) Program
1:10 pm   Opportunity for Public Comment on Measures Under Consideration for ASCQR
1:20 pm   Pre-Rulemaking Input Ambulatory Surgical Center Quality Reporting (ASCQR)—Consent Calendar 3
Jeff Jacobs, The Society of Thoracic Surgeons Marisa Valdes, Baylor Scott & White Health
Programs under consideration: Ambulatory Surgical Center Quality Reporting Program
  1. Ambulatory Breast Procedure Surgical Site Infection (SSI) Outcome Measure (MUC ID: MUC16-155)
    • Description: This measure is for the risk-adjusted Standardized Infection Ratio (SIR) for all Surgical Site Infections (SSIs) following breast procedures conducted at ambulatory surgery centers (ASCs) among adult patients (ages 18 - 108 years) and reported to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). The measure compares the reported number of surgical site infections observed at an ASC with a predicted value based on nationally aggregated data. The measure was developed collaboratively by the CDC, the Ambulatory Surgery Center Quality Collaboration (ASC QC), and the Colorado Department of Public Health and Environment. CDC is the measure steward.
    • Preliminary analysis summary
      • Contribution to program measure set:This is a fully developed measure and is currently under review by the Patient Safety Standing Committee for NQF endorsement. The Committee recommended the measure for endorsement. The measure should complete the consensus development process (CDP) and receive NQF endorsement.
      • Impact on quality of care for patients:Improved care and a decrease in the number of surgical site infections (SSIs) for patients undergoing breast procedures at ambulatory surgical care centers.
    • Preliminary analysis result: Conditional Support for Rulemaking
    • Notes:





  2. Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures (MUC ID: MUC16-152)
    • Description: **As of 12/2 testing for this measure has been completed**** The measure score is an ASC-level rate of unplanned hospital visits within 7 days of an orthopedic procedure performed at an ASC.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is fully developed and specified andaligns with NQF #2539: Rate of Risk-Standardized, All-Cause, Unplanned Hospital Visits within 7 Days of an Outpatient Colonoscopy Among Medicare Fee-for-Service (FFS) Patients Aged 65 Years and Older and MUC16-153: Hospital Visits following Urology Ambulatory Surgical Center Procedures. Testing results should demonstrate reliability and validity at the facility level in the ambulatory surgical setting. This measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:Improved care, care transitions and minimal unplanned hospital visits within 7 days following orthopedic procedures performed in the ambulatory surgical care setting.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





  3. Hospital Visits after Urology Ambulatory Surgical Center Procedures (MUC ID: MUC16-153)
    • Description: **As of 12/2 testing for this measure has been completed**** The measure score is an ASC-level rate of unplanned hospital visits within 7 days of a urology procedure performed at an ASC.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is fully developed and specified andaligns with NQF #2539: Rate of Risk-Standardized, All-Cause, Unplanned Hospital Visits within 7 Days of an Outpatient Colonoscopy Among Medicare Fee-for-Service (FFS) Patients Aged 65 Years and Older and MUC16-152: Hospital Visits following Orthopedic Ambulatory Surgical Center Procedures. Testing results should demonstrate reliability and validity at the facility level in the ambulatory surgical setting. This measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:Improved care, care transitions and minimal unplanned hospital visits within 7 days following urology procedures performed in the ambulatory surgical care setting.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





1:50 pm   Overview of the Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program
2:00 pm   Opportunity for Public Comment on Measures Under Consideration for IPFQR
2:10 pm   Inpatient Psychiatric Facility Quality Reporting (IPFQR)—Consent Calendar 4
Frank Ghinassi, National Association of Psychiatric Health Systems (NAPHS) Ann Marie Sullivan, Individual Subject Matter Expert Woody Eisenberg, Pharmacy Quality Alliance
Programs under consideration: Inpatient Psychiatric Facility Quality Reporting Program
  1. Medication Continuation following Inpatient Psychiatric Discharge (MUC ID: MUC16-048)
    • Description: **As of 12/2 testing for this measure has been completed**** This measure assesses whether psychiatric patients admitted to an inpatient psychiatric facility (IPF) for major depressive disorder (MDD), schizophrenia, or bipolar disorder (BD) were dispensed a prescription for evidence-based medication within 30 days of discharge. The performance period for the measure is two years.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is fully developed, specified and undergoing testing. The testing results should demonstrate reliability and validity at the facility level in the hospital setting. The measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages inpatient psychiatric facilities to ensure that patients with major depressive disorder (MDD), schizophrenia, or bipolar disorder (BD) are dispensed a prescription for evidence-based medication within 30 days of discharge.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





  2. Identification of Opioid Use Disorder (MUC ID: MUC16-428)
    • Description: The measure assesses the percentage of patients admitted to an inpatient psychiatric facility who were screened and evaluated for opioid use disorder.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is fully developed, specified and undergoing field testing. The testing results should demonstrate reliability and validity at the facility level in the hospital setting. This measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages inpatient psychiatric facilities to screen patients for an opioid use disorder.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





  3. Medication Reconciliation at Admission (MUC ID: MUC16-049)
    • Description: **As of 12/2 testing for this measure has been completed**** ****Changed from requiring reconciliation within 24 hours to requiring reconciliation within 48 hours as of 12/1/16**** This measure assesses the average completeness of medication reconciliations conducted within 24 hours of admission to an inpatient facility.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is fully developed, specified and undergoing field testing. The testing results should demonstrate reliability and validity at the facility level in the hospital setting. This measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages inpatient psychiatric facilities to complete adequate medication reconciliation within 24 hours of admission.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





2:45 pm   Break
3:00 pm   Overview of the Hospital Outpatient Quality Reporting Program (HOQR)
3:10 pm   Opportunity for Public Comment on Measures Under Consideration for HOQR
3:20 pm   Pre-Rulemaking Input Measure on Hospital Outpatient Quality Reporting (OQR)—Consent Calendar 5
Lee Fleisher, Individual Subject Matter Expert Jack Jordan, Individual Subject Matter Expert
Programs under consideration: Hospital Outpatient Quality Reporting Program
  1. Median Time from ED Arrival to ED Departure for Discharged ED Patients (MUC ID: MUC16-055)
    • Description: Median elapsed time from emergency department arrival to emergency room departure for patients discharged from the emergency department
    • Preliminary analysis summary
      • Contribution to program measure set:This eMeasure is fully developed, tested and currently implemented in IQR. This eMeasure uses EHR data rather than chart abstracted data to determine patient arrival and discharge times in the emergency department. Testing data should be provided demonstrating that this eMeasure more accurately determines patient arrival and discharge times compared to the chart abstracted version of the measure (NQF #0496) currently in the HOQR and HIQR programs. This eMeasure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:Reducing the median time from ED arrival to the time of departure from the emergency room potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment.
    • Preliminary analysis result: Conditional Support for Rulemaking
    • Notes:





  2. Median Time to Pain Management for Long Bone Fracture (MUC ID: MUC16-056)
    • Description: Median time from emergency department arrival to time of initial oral, nasal or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF)
    • Preliminary analysis summary
      • Contribution to program measure set:The measure is currently in the Hospital Outpatient Quality Reporting (HOQR) program. The NQF Musculoskeletal Steering Committee agreed that the evidence supporting this measure is insufficient. The measure was de-endorsed in 2014.
      • Impact on quality of care for patients:This measure captures the median time to pain medication administration for long bone fractures for patients in the ED. Median time for pain medication administration does not indicate adequate pain management in the ED related to long bone fractures.
    • Preliminary analysis result: Do Not Support for Rulemaking
    • Notes:





  3. Safe Use of Opioids – Concurrent Prescribing (MUC ID: MUC16-167)
    • Description: Patients age 18 years and older with active, concurrent prescriptions for opioids at discharge, or patients with active, concurrent prescriptions for an opioid and benzodiazepine at discharge from a hospital-based encounter (inpatient, ED, outpatient)
    • Preliminary analysis summary
      • Contribution to program measure set:This newly developed eMeasure was tested at the facility level in the emergency department setting and currently undergoing field testing. The testing results should demonstrate reliability and validity in the outpatient setting for HOQR. The measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages outpatient facilities to identify patients discharged with concurrent prescriptions of opioids or opioids and benzodiazepines and discourage prescriptions for two or more different opioids or opioids and benzodiazepines concurrently.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





3:40 pm   Feedback on Current Measure Sets for ESRD QIP, PCHQR, ASCQR, IPFQR, Readmissions, HACs, and OQR
4:40 pm   Opportunity for Public Comment
4:55 pm   Summary of Day
Kate McQueston, Project Manager

5:00 pm   Adjourn
Day 2  
8:30 am   Breakfast
9:00 am   Welcome and Review of Day 1
Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair; Ronald Walters, MAP Hospital Workgroup Co-Chair; Melissa Mariñelarena, Senior Director, NQF

9:15 am   PROMIS Discussion
Ashley Wilder Smith, PhD, MPH, National Cancer Institute

10:15 am   Overview of the Hospital Inpatient Quality Reporting (HIQR) Program and Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs) (Meaningful Use)
10:25 am   Opportunity for Public Comment on Measures Under Consideration for HIQR and Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs) (Meaningful Use)
10:35 am   Pre-Rulemaking Input Measure Sets: Hospital Inpatient Quality Reporting (IQR) and Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs) (Meaningful Use)—Consent Calendar 6
Marsha Manning, University of Michigan David Engler, America's Essential Hospitals Jennifer Eames Huff, Mothers Against Medical Error
Programs under consideration:
  1. Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and Alcohol & Other Drug Use Disorder Treatment at Discharge (MUC ID: MUC16-180)
    • Description: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder 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 alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3) describes patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is NQF-endorsed at the facility level in the hospital/acute care setting. This measure is currently in the IPFQR program. However, no scientific evidence provided to demonstrate that patients who received a prescription at discharge for the treatment of alcohol or drug use disorder or a referral for addictions treatment received treatment after discharge.
      • Impact on quality of care for patients:This measure encourages hospitals to provide patients with a prescription for the treatment of alcohol or drug use disorder or a referral for addictions treatment.
    • Preliminary analysis result: Do Not Support for Rulemaking
    • Notes:





  2. Alcohol Use Brief Intervention Provided or Offered and Alcohol Use Brief Intervention (MUC ID: MUC16-178)
    • 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. 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 [temporarily suspended]).
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is NQF-endorsed at the facility level in the hospital/acute care setting. This measure is currently in the IPFQR program; no implementation issues have been identified.
      • Impact on quality of care for patients:This measure encourages hospitals to provide brief interventions to patients with unhealthy alcohol use.
    • Preliminary analysis result: Support for Rulemaking
    • Notes:





  3. Alcohol Use Screening (MUC ID: MUC16-179)
    • Description: Hospitalized patients 18 years of age and older who are screened within the first three days of admission using a validated screening questionnaire for unhealthy alcohol use. This measure is 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 [temporarily suspended]).
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is NQF-endorsed at the facility level in the hospital/acute care setting. This measure is currently in the IPFQR program and publicly reported on Hospital Compare. No implementation issues have been identified.
      • Impact on quality of care for patients:This measure encourages hospitals to screen patients for unhealthy alcohol use.
    • Preliminary analysis result: Support for Rulemaking
    • Notes:





  4. Patient Panel Smoking Prevalence IQR (MUC ID: MUC16-068)
    • Description: Percentage of hospital patient panel who currently smoke according to the EHR structured data
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is not fully developed and tested in the acute inpatient setting. A more comprehensive measure, MUC16-50 Tobacco Use Screening (TOB-1), that likely captures smoking status has been proposed for IQR.
      • Impact on quality of care for patients:A more comprehensive measure that focuses on tobacco screening improves the quality of tobacco-cessation interventions patients receive while hospitalized.
    • Preliminary analysis result: Do Not Support for Rulemaking
    • Notes:





11:00 am   Break
11:15 am   IQR Continued—Consent Calendar 7
Kimberly Glassman, Nursing Alliance for Quality CareNancy Foster, American Hospital Association Martin Hatlie, Project Patient Care Mimi Huizinga, Premier, Inc.
Programs under consideration:
  1. Follow-Up After Hospitalization for Mental Illness (MUC ID: MUC16-165)
    • Description: The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure, NQF #0576, is specified and tested at the health plan level; therefore, performance on the measure cannot be attributed to the facility as currently specified. Additionally, problems encountered with the initial measure results in the IPFQR program should be resolved prior to implementing the measure in additional programs.
      • Impact on quality of care for patients:This measure can help bridge the gap between the inpatient setting and outpatient treatment services for individuals with serious mental illness.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





  2. Measure of Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures (MUC ID: MUC16-262)
    • Description: The measure estimates the hospital-level quality of informed consent documents for elective procedures for fee-for-service (FFS) Medicare patients. The outcome is defined as the quality of the informed consent document, as evaluated using an instrument developed for this purpose, the Abstraction Tool. A sample of hospitals’ informed consent documents are evaluated and hospital-level performance will be derived by aggregating these individual informed consent document quality scores. The measure is broadly applicable to a range of procedures, including elective cardiac, orthopedic, and urological procedures, that are performed in the hospital.
    • Preliminary analysis summary
      • Contribution to program measure set:The measure is the first step towards improving the practice of informed consent through quality measurement, and may compliment or serve as a platform for other measures of high-quality, patient-centered decision making. The reliability testing results should demonstrate hospital-level reliability. In addition, the measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:Consistent and patient-centered standards based on existing guidelines for informed consent can lead to improved patient autonomy, patient safety, and high-quality decision making.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





IQR Continued—Consent Calendar 8
Brock Slabach, National Rural Health Association Andrea Benin, Children's Hospital Association Wei Ying, Blue Cross Blue Shield of Massachusetts Karen Shehade, Medtronic-Minimally Invasive Therapy Group
Programs under consideration:
  1. Appropriate Documentation of a Malnutrition Diagnosis (MUC ID: MUC16-344)
    • Description: Appropriate documentation of a malnutrition diagnosis for patients age 65 and older admitted to inpatient care who are found to be malnourished based on a nutrition assessment.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is currently under review in NQF’s Health and Well-Being 2015-2017 project. The Standing Committee agreed that the evidence provided to support the measure was not sufficient. The measure did not pass the Evidence criterion and was not recommended for NQF endorsement.
      • Impact on quality of care for patients:This measure encourages documentation of a malnutrition diagnosis for patients = 65 years who have a completed nutrition assessment in their medical record.
    • Preliminary analysis result: Do Not Support for Rulemaking
    • Notes:





  2. Completion of a Malnutrition Screening within 24 Hours of Admission (MUC ID: MUC16-294)
    • Description: Completion of a malnutrition screening using a validated screening tool to determine if a patient is at-risk for malnutrition, within 24 hours of admission to the hospital.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is currently under review in NQF’s Health and Well-Being 2015-2017 project. The Standing Committee did not reach consensus on the Evidence Criterion during the in-person meeting in September. The measure must pass the evidence criterion and be recommended for endorsement.
      • Impact on quality of care for patients:This measure encourages documentation of a malnutrition screening within 24 hours for patients >18 years admitted into the acute inpatient care setting, which is the first step in nutrition care.
    • Preliminary analysis result: Conditional Support for Rulemaking
    • Notes:





  3. Completion of a Nutrition Assessment for Patients Identified as At-Risk for Malnutrition within 24 Hours of a Malnutrition Screening (MUC ID: MUC16-296)
    • Description: Patients age 65 years and older identified as at-risk for malnutrition based on a malnutrition screening who have a nutrition assessment documented in the medical record within 24 hours of the most recent malnutrition screening.
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is currently under review in NQF’s Health and Well-Being 2015-2017 project. The Standing Committee did not reach consensus on the Evidence Criterion during the in-person meeting in September. The measure must pass the evidence criterion and be recommended for endorsement.
      • Impact on quality of care for patients:This measure encourages documentation of a malnutrition assessment within 24 hours of the most recent malnutrition screening for patients = 65 years so that a dietitian can subsequently recommend a nutrition care plan that includes appropriate interventions to address the patient's malnutrition.
    • Preliminary analysis result: Conditional Support for Rulemaking
    • Notes:





  4. Nutrition Care Plan for Patients Identified as Malnourished after a Completed Nutrition Assessment (MUC ID: MUC16-372)
    • Description: Documentation of a nutrition care plan for those patients age 65 and older admitted to inpatient care who are found to be malnourished based on a completed nutrition assessment
    • Preliminary analysis summary
      • Contribution to program measure set:This measure is currently under review in NQF’s Health and Well-Being 2015-2017 project. The Standing Committee did not reach consensus on the Validity Criterion during the in-person meeting in September. The measure must pass the validity criterion and be recommended for endorsement.
      • Impact on quality of care for patients:This measure encourages documentation of a nutrition care plan for patients = 65 years with a finding of malnutrition. The Nutrition care plan may include completed assessment results, treatment goals, prioritization based on treatment severity, prescribed treatment/intervention, identification of members of the care team and a timeline for patient follow-up.
    • Preliminary analysis result: Conditional Support for Rulemaking
    • Notes:





12:30 pm   Lunch
1:00 pm   IQR Continued—Consent Calendar 9
Gregory Alexander, Individual Subject Matter Expert Lindsey Wisham, Individual Subject Matter Expert Lee Fleisher, Individual Subject Matter Expert Jack Jordan, Individual Subject Matter Expert
Programs under consideration:
  1. Safe Use of Opioids – Concurrent Prescribing (MUC ID: MUC16-167)
    • Description: Patients age 18 years and older with active, concurrent prescriptions for opioids at discharge, or patients with active, concurrent prescriptions for an opioid and benzodiazepine at discharge from a hospital-based encounter (inpatient, ED, outpatient)
    • Preliminary analysis summary
      • Contribution to program measure set:This newly developed eMeasure was tested at the facility level in the emergency department setting and currently undergoing field testing. The testing results should demonstrate reliability and validity in the hospital setting for IQR. The measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages hospitals to identify patients discharged with concurrent prescriptions of opioids or opioids and benzodiazepines and discourage prescriptions for two or more different opioids or opioids and benzodiazepines concurrently.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





  2. Influenza Immunization (IMM-2) (MUC ID: MUC16-053)
    • 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.
    • Preliminary analysis summary
      • Contribution to program measure set:The Health and Well-Being Standing Committee acknowledged the importance of this hospital-based measure, but did not believe the narrowing performance gaps were clinically significant in the chart-abstracted version of the measure (#1659). No data/evidence provided demonstrating that this eMeasure addresses a performance gap in IQR.
      • Impact on quality of care for patients:Approximately 94.0% of acute-care hospitalized patients are screened and vaccinated for influenza prior to discharge based on data from the chart-abstracted version of this measure (#1659). No evidence was provided that this eMeasure will increase the percentage of patients receiving influenza vaccine.
    • Preliminary analysis result: Do Not Support for Rulemaking
    • Notes:





  3. Tobacco Use Screening (TOB-1) (MUC ID: MUC16-050)
    • Description: This measure assesses the proportion of hospitalized adult patients who were comprehensively screened (or refused screening) within 3 days prior through 1 day after admission for tobacco use within the 30 days prior to the screening.
    • Preliminary analysis summary
      • Contribution to program measure set:This eMeasure is fully developed and specified at the facility level in the hospital setting. The measure is undergoing field testing. The testing results should demonstrate reliability and validity in the acute care setting. The eMeasure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages hospitals to ask all patients if they use tobacco and document their tobacco use status on a regular basis.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





  4. Use of Antipsychotics in Older Adults in the Inpatient Hospital Setting (MUC ID: MUC16-041)
    • Description: Proportion of inpatient hospitalizations for patients 65 years of age and older who do not demonstrate a threat to themselves or others but who receive antipsychotic medication therapy.
    • Preliminary analysis summary
      • Contribution to program measure set:This newly developed eMeasure is fully developed and specified. The measure is currently undergoing field testing. The testing results should demonstrate reliability and validity at the facility level in the hospital setting. In addition, the measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages hospitals against using antipsychotics as a standard first line of treatment for patients experiencing aggressive behavior unless they present a threat to themselves or their caregivers.
    • Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
    • Notes:





2:00 pm   Feedback on Current Measure Sets for IQR and VBP
2:45 pm   Opportunity for Public Comment
2:55 pm   Wrap Up and Next Steps
Kate McQueston, Project Manager

3:00 pm   Adjourn