Table of Contents. Current and Proposed CMS Quality Measures for Reporting in 2014 through 2019 Revised 07/25/2014

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1 Table of Contents Current Proposed CMS Quality Measures for Reporting in through 2019 Revised 07/25/ Inpatient Measures Collected Submitted by Hospital AMI/Emergency Department/ Immunization Page 2 Heart Failure/Pneumonia/Stroke/Sepsis Page 3 Surgical Care Improvement Page 4 VTE/ Perinatal Care/Pediatric Page 5 NHSN Measures/Structural/Patient Experience of Care Page 6 Claims Based Measures Calculated by CMS (Inpatient) Mortality/Readmissions Page 7 Surgical Complications/AHRQ/Nursing Sensitive/HACs Page 8 Cost Efficiency Page 9 Outpatient Measures Collected Submitted by Hospital Cardiac Care/ED /Pain Management/Stroke/Surgery/Other Page 10 NHSN/Structural Measures Page 11 Claims Based Measures Calculated by CMS (Outpatient) Imaging Efficiency Page 11 Ambulary Surgery Center Measures Collected Submitted by Hospital -Abstracted Measures/NHSN Measures/Structural Page 12 Claims Based Measures Calculated by CMS (ASC) Endoscopy Page 12 Long-Term Care Hospital Measures Collected Submitted by Hospital LTCH Measures/NHSN Measures Page 13 Claims Based Measures Calculated by CMS (LTCH) Readmission Measures Page 13 Inpatient Psychiatric Facility Measures Collected Submitted by Hospital HBIPS/Substance Use/IMM/NHSN/Structural Page 14 Claims Based Measures Calculated by CMS (IPF) Clinical Quality of Care Measures Page 14 Inpatient Rehabilitation Facility Measures Collected Submitted by Hospital IRF Measures/NHSN Measures Page 15 Claims Based Measures Calculated by CMS (IRF)) Readmission Measures Page 15 End-Stage Renal Disease Facility Measures Collected Submitted by Hospital NHSN Measures/Measures Reported through CROWNWeb Page 16 Claims Based Measures Calculated by CMS (ESRD) Clinical Measures/Reporting Measures Page 16 PPS-Exempt Cancer Hospital Measures Collected Submitted by Hospital Cancer Related/SCIP/HCAHPS Page 17 NHSN Measures Page 18

2 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ INPATIENT Current Proposed Measures Collected Submitted by Hospital HIQRP VBP HITECH MEASURE Acute Myocardial Infarction (AMI) AMI-1 Aspirin at arrival Reporting effective date Currently suspended Affects APU after AMI-2 Aspirin prescribed at discharge Jan ecqm AMI-3 ACEI or ARB for LVSD AMI-5 Beta blocker prescribed at discharge AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI) Currently suspended Currently suspended after after *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Reporting effective date Affects Reimburse ment Page Included in Meaningful Use* July 2011 FY /31/ ecqm AMI-10 Statin prescribed at discharge Jan ecqm Emergency Department (ED) ED-1 Median time from ED arrival ED departure for admitted ED Patients ED-2 Admit decision time ED departure time for admitted patients ED-3 Median time from ED arrival ED departure for discharged ED patients Immunization IMM-1 Pneumococcal Immunization Jan 2012 Suspend after Dec 2013 July FY 2013 Jan 2012 FY Stage 1 Jan 2012 FY Stage 1 FY Suspend IMM-2 Influenza Immunization Jan 2012 FY Jan

3 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ Heart Failure (HF) HF-1 Discharge instructions HF-2 Left ventricular function assessment HF-3 ACEI or ARB for left ventricular syslic dysfunction Pneumonia (PN) PN-3b Blood culture performed before first antibiotic received in hospital PN-6 Appropriate initial antibiotic selection Sepsis Septic Shock Severe Sepsis Septic Shock: Management Bundle Measure Stroke STK-1 VTE Prophylaxis for patients with ischemic or hemorrhagic stroke STK-2 Ischemic stroke patients discharged on antithrombotic therapy STK-3 Anticoagulation therapy for atrial fibrillation/flutter STK-4 Thrombolytic Therapy for Acute ischemic stroke patients STK-5 Antithrombotic therapy by the end of hospital day two Dec 2013 Dec Dec 2013 Dec /31/ Jan Jan 2013 Jan /31/ Jan /31/ 2016 ecqm FY2017 FY FY ecqm FY ecqm *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures 2013 July July 2011 FY 2013 FY Page Stage 1 Stage 1 Jan 2013 FY Stage 1 Jan /31/ FY ecqm Stage 1

4 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ STK-6 Discharged on statin medication Jan 2013 FY Stage 1 STK-8 Stroke education Jan 2013 FY Stage 1 STK-10 Assessed for rehabilitation services Jan 2013 Dec Surgical Care Improvement Project (SCIP) SCIP-Infection-1 Prophylactic antibiotic received within 1 hour prior surgical incision SCIP-Infection-2 Prophylactic antibiotic selection for surgical patients SCIP-Infection-3 Prophylactic antibiotics discontinued within 24 hours after surgery end time SCIP-Infection-4 Cardiac surgery patients with controlled 6AM posperative serum glucose 01/ revise controlled glucose hours post-cardiac surgery SCIP-Infection-6 Surgery patients with appropriate hair removal SCIP-Infection-9 Posperative urinary catheter removal on post operative day 1 or 2 SCIP-Infection-10 Perioperative temperature management SCIP-Cardiovascular-2 Surgery patients on a beta blocker prior arrival who received a beta blocker during the perioperative period 12/31/ Dec Dec Dec Currently suspended Dec Dec 2013 Dec FY ecqm ecqm ecqm 2016 after after ecqm after *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures July July 2011 July 2011 July April 2012 July 2011 FY 2013 FY 2013 after Dec 2016 FY FY 2013 FY 2016 FY 2013 after Page Stage 1

5 SCIP-VTE-1 Venous thromboembolism (VTE) prophylaxis ordered for surgery patients SCIP-VTE-2 VTE prophylaxis within 24 hours pre/post surgery 12/31/2012 Dec after Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ 12/31/2012 July 2011 FY 2013 after Venous Thromboembolism (VTE) VTE-1 Venous thromboembolism Prophylaxis Jan 2013 FY Stage 1 VTE-2 Intensive care unit venous thromboembolism prophylaxis VTE-3 Venous thromboembolism patients with anticoagulation overlap therapy VTE-4 Venous thromboembolism patients receiving unfractionated heparin with dosages/platelet count moniring by procol or nomogram VTE-5 Venous thromboembolism discharge instructions VTE-6 Incidence of potentially-preventable venous thromboembolism Jan 2013 FY Stage 1 Jan 2013 FY Stage 1 Jan 2013 Dec FY ecqm Stage 1 Jan 2013 FY Stage 1 Jan 2013 FY Stage 1 Perinatal Care (PC) Aggregate Data Submission by Web-Based Tool (QualityNet) PC-01 Elective delivery prior 39 completed Jan 2013 FY weeks of gestation PC-05 Exclusive breast milk feeding Jan FY2017 ecqm Pediatric Measures Home management plan of care document given pediatric asthma patient/caregiver Jan ecqm Healthy term newborn Jan ecqm Hearing screening prior hospital discharge for newborns Jan ecqm *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page - 5 -

6 Healthcare Associated Infections Reported NHSN Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ Central Line Associated Bloodstream Infection Exp include some non-icu wards Exp Jan Exp Feb 2013 FY Continue & beyond Surgical Site Infection Jan 2012 FY Jan Catheter-Associated Urinary Tract Infection Exp include some non-icu wards Jan 2012 Exp Jan FY Exp Jan MRSA Bacteremia Jan 2013 FY Clostridium Difficile (C. Diff) Jan 2013 FY Healthcare Personnel Influenza Vaccination Jan 2013 FY Structural Measures Participation in a systematic database for cardiac surgery Participation in a systematic clinical database registry for stroke care Participation in a systematic clinical database registry for nursing sensitive care after 2016 Participation in a systematic clinical database registry for general surgery Safe Surgery checklist use 2012 Data Reported 2013 Data Reported FY Patients Experience of Care HCAHPS survey 2 items + 1 measure added FY July 2011 FY 2013 To begin the alignment of quality measure reporting under the Hospital IQR Medicare EHR Incentive Programs, CMS is offering hospitals two options meet IQR reporting requirements for the VTE, Stroke, ED PC measure sets. These four sets are included in both programs. Under the Hospital IQR Program for the payment determination, hospitals may choose either (1) electronically report at least one quarter of CY quality measure data for up 16 of the measures, or (2) continue reporting all of these measures using chart-abstracted data for all four quarters of CY. *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page - 6 -

7 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ Claims Based Measures Calculated by CMS (Inpatient) HIQRP VBP MEASURE Reporting effective date Affects APU Reporting effective date Affects Reimbursement Mortality Measures (Medicare Patients) Hospital 30-day, all-cause, risk-stardized 7/1/11 mortality rate following AMI hospitalization for patients 18 older Hospital 30-day, all-cause, risk-stardized 7/1/11 mortality rate following heart failure hospitalization for patients 18 older Hospital 30-day, all-cause, risk-stardized 7/1/11 mortality rate following pneumonia hospitalization Hospital 30-day, all-cause, risk-stardized mortality rate following COPD hospitalization Stroke 30-day mortality rate Hospital 30-day, all-cause, risk-stardized mortality rate following CABG surgery Readmission Measures (Medicare Patients) Hospital 30-day,all-cause, risk-stardized readmission rate following AMI hospitalization Hospital 30-day, all-cause, risk-stardized readmission rate following heart failure hospitalization Hospital 30-day, all-cause, risk-stardized readmission rate following pneumonia hospitalization Hospital-level 30-day, all-cause, riskstardized FY readmission rate following elective primary tal hip/tal knee arthroplasty Hospital-wide all-cause unplanned FY readmission (HWR) Hospital 30-day,all-cause, risk-stardized readmission rate following COPD hospitalization Stroke 30-day risk stardized readmission Hospital 30-day,all-cause, unplanned, riskstardized readmission rate following CABG surgery *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page - 7 -

8 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ Surgical Complications Hip/Knee: Hospital-level risk stardized FY FY 2019 complication rate (RSCR) following elective primary tal hip\tal knee arthroplasty AHRQ Measures PSI 06 Iatrogenic pneumothorax, adult End 2012 after FY PSI 11 Post operative respirary failure End 2012 after FY PSI 12 Post operative PE or DVT End 2012 after FY PSI 14 Post operative wound dehiscence End 2012 after FY PSI 15 Accidental puncture or laceration End 2012 after FY IQI 11 Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) End 2012 after FY IQI 19 Hip fracture mortality rate End 2012 after FY PSI 90 Complication/patient safety for selected indicars (composite) 10/15/2012 FY Readopt for FY 2019 IQI 91Mortality for selected medical conditions (composite) End 2012 after FY AHRQ Nursing Sensitive Care PSI-4 Death among surgical inpatients with serious, treatable complications Hospital Acquired Conditions Foreign object retained after surgery End 2012 after FY Air embolism End 2012 after FY Blood incompatibility End 2012 after FY Pressure Ulcer stages III & IV End 2012 after FY Falls Trauma (Includes: fracture, dislocation, intracranial injury, crushing injury, burn, electric shock End 2012 after FY Vascular catheter-associated infection End 2012 after FY Catheter-associated urinary tract infection (UTI) End 2012 after FY Manifestations of poor glycemic control End 2012 after FY beyond *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page - 8 -

9 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ Cost Efficiency Medicare spending per beneficiary 05/15/2012 FY May 2013 FY Add RRB beneficiaries for AMI payment per episode of care Hospital-level, risk-stardized 30-day episode-of-care payment measure for heart failure Hospital-level, risk-stardized 30-day episode-of-care payment measure for pneumonia *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page - 9 -

10 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ OUTPATIENT Current Proposed Measures Collected Submitted by Hospital HOQRP Cardiac Care (AMI CP) Measures OP-1 Median time fibrinolysis OP-2 Fibrinolytic therapy received within 30 minutes of ED arrival OP-3 Median time transfer another facility for acute coronary intervention OP-4 Aspirin at arrival after CY 2016 OP-5 Median time ECG ED Throughput OP-18 Median time from ED arrival ED Jan 2012 CY 2013 departure for discharged ED patients OP-20 Door diagnostic evaluation by a qualified Jan 2012 CY 2013 medical professional Pain Management OP-21 Median time pain management for long Jan 2012 CY 2013 bone fracture Stroke OP-23 Head CT or MRI scan results for acute Jan 2012 CY 2013 ischemic stroke or hemorrhagic stroke patients who received head CT or MRI scan interpretation within 45 minutes of ED arrival Surgery Measures OP-6 Timing of antibiotic prophylaxis after CY 2016 OP-7 Prophylactic antibiotic selection for surgical patients after CY Abstracted Measures with Aggregate Data Submission by Web-Based Tool (QualityNet) OP-22 ED patient left without being seen Jan-Jun 2012 Data CY 2013 OP-29 Endoscopy/Poly surveillance: Appropriate follow-up interval for normal colonoscopy in average risk patients OP-30 Endoscopy/Poly Surveillance: Colonoscopy Interval for Patients with a Hisry of Adenomaus Polyps Avoidance of Inappropriate Use OP-31 Cataracts Improvement in patients visual function within 90 days following cataract surgery Reported Jul-Aug 2012 April 1, CY 2016 April 1, CY 2016 January 1, CY 2016 for CY 2016 beginning CY2017 *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page

11 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ Measures Reported via NHSN OP-27 Influenza vaccination coverage among healthcare personnel Structural Measures OP-12 The ability for providers with health information technology (HIT) receive laborary data electronically directly in their qualified/certified electronic health record (EHR) system as discrete searchable data OP-17 Tracking clinical results between visits OP-25 Safe Surgery Checklist Use Op-26 Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures 10/1/ - 3/31/ Reported by 5/15/ Jan- Jun 2011Data Reported Jul-Aug 2011 Jan-Jun 2012 Data Reported Jul-Aug Data Reported in Data Reported in 2013 CY 2016 CY 2012 CY 2013 CY CY Claims Based Measures Calculated by CMS (Outpatient) HOQRP Imaging Efficiency Measures OP-8 MRI lumbar spine for low back pain OP-9 Mammography follow-up rates OP-10 Abdomen computed mography (CT) use of contrast material OP-11 Thorax CT use of contrast material OP-13 Cardiac imaging for preoperative risk CY 2010 CY 2012 assessment for non-cardiac low-risk surgery OP-14 Simultaneous use of brain CT sinus CY 2010 CY 2012 CT OP-15 Use of brain CT in the ED for atraumatic Deferred Deferred headache Endoscopy Measure OP-32 Facility 7-Day Risk-Stardized Hospital Visit Rate after Outpatient Colonoscopy CY CY 2017 *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page

12 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ AMBULATORY SURGERY CENTER Current Proposed Measures Collected Submitted by Hospital ASCQRP -Abstracted Measures Reported Through Quality Data Codes on Part B Claims ASC-1 Patient Burn Oct 2012 CY ASC-2 Patient Fall Oct 2012 CY ASC-3 Wrong Site, Wrong Side, Wrong Patient, Oct 2012 CY Wrong Procedure, Wrong Implant ASC-4 Hospital Transfer/Admission Oct 2012 CY ASC-5 Prophylactic Intravenous (IV) Antibiotic Timing Oct 2012 CY -Abstracted Measures with Aggregate Data Submission by Web-Based Tool (QualityNet) ASC-9 Endoscopy/Poly surveillance: Appropriate April 1, CY 2016 follow-up interval for normal colonoscopy in average risk patients ASC-10 Endoscopy/Poly Surveillance: Colonoscopy Interval for Patients with a Hisry of Adenomaus Polyps Avoidance of April 1, CY 2016 Inappropriate Use ASC-11 Cataracts Improvement in patient s visual function within 90 days following cataract surgery January 1, Healthcare Associated Infections Reported NHSN ASC-8 Influenza Vaccination Coverage among Oct CY2016 Healthcare Personnel Structural Measures ASC-6 Safe Surgery Checklist Use 2012 ASC-7 ASC Facility Volume Data on Selected ASC Surgical Procedures 2012 CY 2016 for CY2016 beginning CY 2017 Claims Based Measures Calculated by CMS ASCQR Program Endoscopy Measure ASC-12 Facility 7-Day Risk-Stardized Hospital Visit Rate after Outpatient Colonoscopy CY CY 2017 *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page

13 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ LONG-TERM CARE HOSPITAL Current Proposed Measures Collected Submitted by Hospital LTCHQR Program -Abstracted Measures Reported Using the LTCH CARE Data Set (QIES ASAP) Percent of Residents or Patients with Pressure Oct 2012 FY Ulcers that are New or Worsened (Short-Stay) Percent of residents or patients who were Oct assessed appropriately given the seasonal Influenza Vaccine (Short-Stay) Percent of Residents Experiencing One or More Jan 2016 FY 2018 Falls with Major Injury April 2016 Percent of LTCH Patients with an Admission April 2016 FY 2018 Discharge Functional Assessment a Care Plan that Addresses Function in Mobility among LTCH Patients Requiring Ventilar Support April 2016 FY 2018 Healthcare Associated Infections Reported NHSN Urinary Catheter-Associated Urinary Tract Oct 2012 FY Infection (CAUTI) Central Line Catheter-Associated Bloodstream Oct 2012 FY Infection (CLABSI) Influenza Vaccination coverage among Oct healthcare personnel Facility-Wide Inpatient Hospital-onset MRSA Jan Bacteremia Outcome Measure Facility-wide Inpatient Hospital-onset Jan Clostridium difficile Infection (CDI) Outcome Measure Ventilar-Associated Event Outcome Measure Jan 2016 FY 2018 Claims Based Measures Calculated by CMS (Long-Term Care Hospitals) LTCHQR Program Readmission Measures (Medicare Patients) All-cause Unplanned Readmission Measure for 30 days Post-Discharge from LTCH Jan 2013 *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page

14 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ INPATIENT PSYCHIATRIC FACILITIES Current Proposed Measures Collected Submitted by Hospital IPFQR Program Hospital Based Inpatient Psychiatric Services HBIPS-2 Hours of physical restraint use Oct 2012 FY HBIPS-3 Hours of seclusion use Oct 2012 FY HBIPS-4 Patients discharged on multiple Oct 2012 FY antipsychotic medications HBIPS-5 Patients discharged on multiple Oct 2012 FY antipsychotic medications with appropriate justification HBIPS-6 Post-discharge continuing care plan Oct 2012 FY created HBIPS-7 Post-discharge continuing care plan Oct 2012 FY transmitted next level of care provider upon discharge SUB-1 Alcohol Use Screening Jan TOB-1 Tobacco Use Screening Jan TOB-2 Tobacco Use Treatment Provided or Jan Offered IMM-2 Influenza Immunization Oct Healthcare Associated Infections Reported NHSN Influenza Vaccination Coverage Among Oct Healthcare Personnel Structural Measure IPF Assessment of Patient Experience of Care Request for Information Jan Assessment of Patient Experience of Care Reported Jul/Aug Use of an Electronic Health Record (EHR) Reported Jul/Aug Does not affect payment determination Claims Based Measures Calculated by CMS IPFQR Program Clinical Quality of Care Measure Follow-up After Hospitalization for Mental Illness July 2013 *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page

15 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ INPATIENT REHABILITATION FACILITY Current Proposed Measures Collected Submitted by Hospital IRF QRP -Abstracted Measures Reported Through IRF-Patient Assessment Instrument (IRF-PAI) Percent of Residents with New or Worsened Pressure Ulcers (Application of NQF#0678) Oct 2012 in Oct FY 2016 Percent of Residents or Patients with Pressure Oct Ulcers That are New or Worsened (Short-Stay) (NQF#0678) Percent of Residents or Patients Who Were Oct Assessed Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF#0680) Quality Measures Reported NHSN Urinary Catheter-Associated Urinary Tract Infection (CAUTI) (NQF#0138) Influenza Vaccination Coverage among Healthcare Personnel (NQF#0431) NHSN Facility-wide Inpatient Hospital-Onset MRSA Bacteremia Outcome Measure (NQF1716) NHSN Facility-wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure (NQF1717) Oct 2012 FY Oct Jan Jan Claims Based Measures Calculated by CMS (Inpatient Rehab Facilities) IRF QRP Readmission Measures (Medicare Patients) All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities (NQF#2502) Reported in CY 2016 using CY 2013 CY claims data *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page

16 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ END-STAGE RENAL DISEASE FACILITY Current Proposed Measures Collected Submitted by Facility ESRD QIP MEASURE Reporting effective date Affects Reimbursement Healthcare Associated Infections Reported through NHSN Dialysis Event Reporting Measure replace with NHSN Bloodstream Infection in Hemodialysis Outpatients Measures Reported through CROWNWeb ICH CAHPS Beginning in requires submission CMS via CMS approved ICH CAHPS survey vendor 2012 Revise Jan 2012 PY Revise PY 2016 PY PY 2016 Mineral Metabolism 2012 PY Proportion of patients with hypercalcemia PY 2016 (NQF#1454) Claims Based Measures Calculated by CMS ESRD QIP MEASURE Reporting effective date Affects Reimbursement Clinical Measures Hemoglobin greater than 12g/dL Jan 2010 PY 2012 after PY 2016 URR hemodialysis adequacy Jan 2010 PY 2012 after PY Hemodialysis Vascular Access-Maximizing Jan 2012 PY Placement of AVF (NQF#0257) Hemodialysis Vascular Access-Minimizing use Jan 2012 PY of Catheters as Chronic Dialysis Access (NQF#0256) Hemodialysis Adequacy Minimum Delivered CY 2013 PY Hemodialysis Dose (NQF#0249) Perineal Dialysis Adequacy Delivered Dose CY 2013 PY of Perineal Dialysis Above Minimum (NQF#0318) Minimum spkt/v for Pediatric Hemodialysis CY 2013 PY Patients (NQF#1423) Stardized Readmission Ratio CY CY 2017 Reporting Measures Anemia Management CY 2013 PY *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page

17 Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ PPS EXEMPT CANCER HOSPITALS Current Proposed Measures Collected Submitted by Facility PCHQR Program MEASURE Reporting effective date Affects Reimbursement Adjuvant Chemotherapy is considered or Jan 2013 FY administered within 4 months (120 days) of surgery patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer Combination Chemotherapy is considered or Jan 2013 FY administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c, or Stage II or III hormone recepr negative Breast Cancer Adjuvant Hormonal Therapy Jan 2013 FY Oncology-Radiation Dose Limits Normal Jan Tissues Oncology: Plan of Care for Pain Jan Oncology: Pain Intensity Quantified Jan Prostate Cancer-Adjuvant Hormonal Therapy for Jan High-Risk Patients Prostate Cancer-Avoidance of Overuse Jan Measure-Bone Scan for Staging Low-Risk Patients Beam radiotherapy for bone metastases Jan Surgical Care Improvement Project (SCIP) Prophylactic antibiotic received within 1 hour Jan prior surgical incision Prophylactic antibiotic selection for surgical Jan patients Prophylactic antibiotics discontinued within 24 Jan hours after surgery end time Posperative urinary catheter removal on post Jan operative day 1 or 2 Surgery patients on beta blocker therapy prior Jan admission who received a beta blocker during the perioperative period Surgery patients who received appropriate VTE Jan prophylaxis within 24 hrs prior surgery 24 hrs after surgery end time Patients Experience of Care HCAHPS survey April *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page

18 Healthcare Associated Infections Reported through NHSN Catheter Associated Urinary Tract Infection Jan 2013 FY Central Line Associated Bloodstream Infection Jan 2013 FY Surgical Site Infection Jan FY Current Proposed Quality Measures for Reporting in through 2019 Revised 07/25/ Prepared by the Indiana Hospital Association 07/25/ *HITECH Meaningful Use forward: Participate in 16 measures from a menu of 29 measures Page