Patient Engagement HCAHPS. HCAHPS Composite 4. HCAHPS Composite 5. Cleanliness of Hospital Environment. Communication about Medicines

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1 Patient Engagement Composite 1 Composite 2 Composite 3 Composite 4 Composite 5 Question 8 Question 9 Composite 6 Composite 7 Question 21 Question 22 Measure Name with Nurses with Doctors Responsiveness of Hospital Staff Pain Management about Medicines Cleanliness of Hospital Environment Quietness of Hospital Environment Discharge Information Care Transitions Overall Rating of Hospital Willingness to Recommend Measure Description their nurses Always communicated well their doctors Always communicated well they Always received help as soon as they wanted their pain was Always well controlled staff Always explained about medicines before giving them their room and bathroom were Always clean the area around their room was Always quiet at night reported they were given information about what to do during their recovery at home Strongly Agree they understood their care when they left the hospital gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) reported Yes they would definitely recommend the hospital Importance/Significance Growing research shows positive associations between patient experience and health outcomes, adherence to recommended medication and treatments, preventative care, health-care resource use and quality and safety of care. Improvement Noted As Increase in percent "always" Data Reported To QualityNet via Survey Vendor Hospital Compare x x x x x x x x x x x Data Available On MBQIP Data Reports x x x x x x x x x x x FMT Reports x x x x x x x x x x x Measure Population Patients discharged from the hospital following at least one overnight stay sometime between 48 hours and 6 weeks ago who are over the age of 18 and did not have a psychiatric principal diagnosis at discharge. Sample Size Requirements Sampling determined by certified vendor Data Collection Approach Survey (typically conducted by a certified vendor) Encounter Period Q1 (Jan - Mar) Q2 (Apr - Jun) Q3 (Jul - Sep) Q4 (Oct - Dec) Submission Period/Deadline July October January April Page 9

2 Patient Engagement Composite 1 Composite 2 Composite 3 Composite 4 Composite 5 Question 8 Question 9 Composite 6 Composite 7 Question 21 Question 22 Data Elements nurses treat you with courtesy and respect? nurses listen carefully to you? nurses explain things in a way you could understand? doctors treat you with courtesy and respect? doctors listen carefully to you? doctors explain things in a way you could understand? after you pressed the call button, you get help as soon as you wanted it?.how often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? how often was your pain well controlled? the hospital staff do everything they could to help you with your pain?.before giving you any new medicine, how often did hospital staff tell you what the medicine was for?.before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? Question: hospital stay how often were your room and bathroom kept clean? Question: how often was the area around your room quiet at night? did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? did you get information in writing about what symptoms or health problems to look out for after you left the hospital? staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left..when I left the hospital, I had a good understanding of the things I was responsible for in managing my health..when I left the hospital, I clearly understood the purpose for taking each of my medications. Question:.Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay? Question:.Would you recommend this hospital to your friends and family? Included Populations Random sample of adult patients across medical conditions between 48 hours and six weeks after discharge. Patients who answered "always" to composite questions Random sample of adult patients across medical conditions between 48 hours and six weeks after discharge. Patients who answered "always" Random sample of adult patients across medical conditions between 48 hours and six weeks after discharge. Patients who answered "always" to composite questions Random sample of adult patients across medical conditions between 48 hours and six weeks after discharge. Patients who answered "9" or "10" Random sample of adult patients across medical conditions between 48 hours and six weeks after discharge. Patients who answered "definitely yes" Excluded Populations Patients who expired in the hospital. Page 10

3 Care Transitions ED Transfer s EDTC-SUB 1 EDTC-SUB 2 EDTC-SUB 3 EDTC-SUB 4 EDTC-SUB 5 EDTC-SUB 6 EDTC-SUB 7 Measure Name Administrative Patient Information Vital Signs Medication information Physician or practitioner generated information Nurse generated information Procedures and tests Percentage of patients who are transferred from an ED to another healthcare that have communication with the receiving within 60 minutes of discharge for: Measure Description physician to physician communication and nurse to nurse communication prior to discharge patient identification information patient s vital signs medication information history and physical and physician orders and plan key nurse documentation elements tests done and results sent Importance/Significance Improvement Noted As Data Reported To Data Available On Data Collection Approach Encounter Period Timely, accurate and direct communication facilitates the handoff to the receiving provides continuity of care and avoids medical errors and redundant tests. Increase in the rate (percent) State Flex Office MBQIP Data Reports Q1 (Jan - Mar) Q2 (Apr - Jun) Q3 (Jul - Sep) Q (Oct - Dec) Submission Period/Deadline February 1 May 1 August 1 November 1 Measure Population Patients admitted to the and transferred from the to another health care Sample Size Requirements submit all cases > 45 - submit 45 cases submit all cases > 15 - submit 15 cases Data Elements. of Patient Encounter.Nurse to Nurse.Physician to Physician. of Patient Encounter.Patient Name.Patient Address.Patient Age.Patient Gender.Patient Contact Information.Patient Insurance Information. of Patient Encounter.Pulse.Respiratory rate.blood pressure.oxygen saturation.temperature.neurological Assessment. of Patient Encounter.Medications Administered in ED.Allergies/Reactions.Home Medication. of Patient Encounter.History and Physical.Reason for Transfer Plan of Care. of Patient Encounter.Nursing Notes.Sensory Status (formerly impairments).catheters.immobilizations.respiratory Support.Oral Restrictions. of Patient Encounter.Tests/Procedures Performed.Tests/Procedure Results Included Populations Statement: All transfers from ED to another healthcare s another healthcare receiving prior to transfer..nurse to nurse communication.physician to physician communication Statement: ED transfers to another healthcare another healthcare receiving within 60 minutes of departure..name.address.age.gender.significant others contact information.insurance Statement: ED transfers to another healthcare another health care receiving within 60 minutes of discharge..pulse.respiratory rate.blood pressure.oxygen saturation.temperature.glasgow score or other neuro assessment for trauma, cognitively altered or neuro patients only Statement: ED transfers to another healthcare patients transferred from an ED to another healthcare receiving hospital within 60 minutes of departure..medications administered in ED.Allergies.Home medications Statement: ED transfers to another healthcare another healthcare receiving within 60 minutes of discharge..history and physical.reason for transfer and/or plan of care Statement: Transfers from an ED to another healthcare another healthcare receiving within 60 minutes of departure..assessments/interventions/r esponse.sensory Status (formerly Impairments).Catheters.Immobilizations.Respiratory support.oral limitations Statement: Transfers from an ED to another healthcare another healthcare receiving hospital within 60 minutes of discharge..tests and procedures done.tests and procedure results sent

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5 Outpatient AMI AMI and Chest Pain ED Throughput Pain Mgmt ED Throughput OP-1 OP-2 OP-3 OP-4 OP-5 OP-18 OP-20 OP-21 OP-22 Measure Name Median time to fibrinolysis (should be analyzed in conjunction with OP-2) Fibrinolytic therapy received within 30 minutes Median time to transfer to another for acute coronary intervention Aspirin at Arrival Median time to ECG Median time from ED Arrival to ED Departure Door to diagnostic evaluation by a qualified medical professional Median time to pain management for long bone fracture Patient left without being seen Measure Description Median time from ED arrival to administration of fibrinolytic therapy in patients with STEMI on the ECG performed closest to ED arrival and prior to transfer. Percentage of outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival. Median number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital. Note: Hospital Compare described measure as "average number of minutes" ED AMI patients or chest pain patients (with probably cardiac chest pain) who received aspirin within 24 hours before ED arrival or prior to transfer Median number of minutes before outpatients with chest pain or possible heart attack got an ECG Note: Hospital Compare described measure as "average number of minutes" Median time from ED arrival to time of departure from the emergency room for patients discharged from the ED. Median time patients spent in the emergency department before they were seen by a healthcare professional Note: Hospital Compare described measure as "average number of minutes" Median time patients who came to the emergency department with broken bones had to wait before receiving pain medication Note: Hospital Compare described measure as "average number of minutes" Percentage of patients who left the emergency department before being seen Importance/Significance Time to fibrinolytic therapy is a strong predictor of outcome in patients with AMI. Nearly 2 lives per 1,000 patients are lost per hour of delay. National guidelines recommend fibrinolytic therapy within 30 minutes of hospital arrival for patients with STEMI. Time to fibrinolytic therapy is a strong predictor of outcome in patients with AMI. Nearly 2 lives per 1,000 patients are lost per hour of delay. National guidelines recommend fibrinolytic therapy within 30 minutes of hospital arrival for patients with STEMI. The early use of primary angioplasty in patients with STEMI results in a significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided, the more effective it is. Times to treatment in transfer patients undergoing primary PCI may influence the use of PCI as an intervention. Current recommendations support a door-to-balloon time of 90 minutes or less. The early use of aspirin in patients with AMI results in a significant reduction in adverse events and subsequent mortality. The benefits of aspirin therapy on mortality are comparable to fibrinolytic therapy. Guidelines recommend patients presenting with chest discomfort or symptoms suggestive of STEMI have a 12-lead ECG performed within 10 minutes of ED arrival. Timely ECGs assist in identifying STEMI patients and impact the choice of reperfusion strategy. This measure will identify the median time to ECG for chest pain or AMI patients and potential opportunities for improvement to decrease the median time to ECG. Reducing patient time in the ED can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. Reducing patient wait time in the ED helps improve access to care, increase capability to provide treatment, reduce ambulance refusals/diversions, reduce rushed treatment environments, reduce delays in medication administration and reduce patient suffering. Patients with bone fractures continue to lack administration of pain medication as part of treatment regimens. When performance measures are implemented for pain management of these patients administration and treatment rates for pain improve. Disparities exist in the administration of pain medication for minorities and children. Reducing patient wait time in the ED helps improve access to care, increase capability to provide treatment, reduce ambulance refusals/diversions, reduce rushed treatment environments, reduce delays in medication administration and reduce patient suffering. Improvement Noted As Increase in the rate (percent) Increase in rate (percent) Decrease in the rate (percent) Data Collection Approach Data Reported To Data Available On Hospital Compare MBQIP Data Reports (Note : Not based on claims data) QualityNet via Online Tool x x x x x x x x x x x x x x x x x FMT Reports x x x x x x x x x Page 13

6 Outpatient AMI AMI and Chest Pain ED Throughput Pain Mgmt ED Throughput OP-1 OP-2 OP-3 OP-4 OP-5 OP-18 OP-20 OP-21 OP-22 Encounter Period Q1 (Jan - Mar) Q2 (Apr - Jun) Q3 (Jul - Sep) Q4 (Oct - Dec) Q1-Q4 (Jan-Dec) Submission Period/Deadline August November February May 15-May Measure Population for whom all of the following are true: or to a Federal Healthcare.A patient age >=18 years Diagnosis for AMI for whom all of the following are true: or to a Federal Healthcare.A patient age >=18 years Diagnosis for AMI for whom all of the following are true: or to a Federal Healthcare.A patient age >=18 years Diagnosis for AMI for whom all of the following are true: or to a Federal Healthcare.A patient age >=18 years Diagnosis for AMI or ICD-10-CM Principal Diagnosis for Chest Pain for whom all of the following are true: or to a Federal Healthcare.A patient age >=18 years Diagnosis for AMI or ICD-10-CM Principal Diagnosis for Chest Pain for whom the following are also true:.patient age >=2 years Diagnosis for Long Bone Fracture NA -This measure uses administrative data and not claims data to determine the measure's denominator population. Sample Size Requirements sample size sample size sample size sample size sample size Submit 63 cases > Submit 96 cases Note: sample size quarterly patient population submit 21 cases > submit 32 cases Submit 63 cases > Submit 96 cases Note: sample size quarterly patient population submit 21 cases > submit 32 cases sample size No sampling - report all cases Data Elements.Birthdate Administration Administration Administration Time.ICD-10-CM Principal Diagnosis.Initial ECG Interpretation.Reason for Delay in Fibrinolytic Therapy Administration Administration Time.Birthdate.ED Departure.ED Departure Time Administration.ICD-10-CM Principal Diagnosis.Initial ECG Interpretation.Reason for Not Administering Fibrinolytic Therapy.Transfer for Acute Coronary Intervention.Birthdate.ECG.ECG.ECG Time.ICD-10-CM Other Diagnosis s.icd-10-cm Principal Diagnosis.Probable Cardiac Chest Pain.Birthdate.ECG.ECG.ECG Time.ICD-10-CM Other Diagnosis s.icd-10-cm Principal Diagnosis.Probable Cardiac Chest Pain.Provider Contact.Provider Contact Time.Provider Contact.Provider Contact Time.Birthdate.ICD-10-CM Principal Diagnosis.Pain Medication.Pain Medication.Pain Medication Time Definition of provider includes:.residents/interns.institutionally credentialed provider.apn/aprns Page 14

7 Outpatient AMI AMI and Chest Pain ED Throughput Pain Mgmt ED Throughput OP-1 OP-2 OP-3 OP-4 OP-5 OP-18 OP-20 OP-21 OP-22 Included Populations.An E/M for or to a Federal healthcare Diagnosis for AMI.ST-segment elevation on the ECG performed closest to ED arrival Administration as defined in the Data Dictionary Statement: ED AMI patients with ST-segment elevation on ECG who received fibrinolytic therapy..an E/M for or to a Federal healthcare Diagnosis for AMI.ST-segment elevation on the ECG performed closest to ED arrival Administration as defined in the Data Dictionary Statement: ED AMI patients whose time from ED arrival to fibrinolysis is 30 minutes or less..an E/M for, or to a Federal healthcare, and Diagnosis for AMI.ST-segment elevation on the ECG performed closest to ED arrival, and.with Transfer for Acute Coronary Intervention as defined in the Data Dictionary.An E/M for to a short term general, or to a Federal healthcare, and Diagnosis for AMI or an ICD-10-CM Principal or Other Diagnosis s for Angina, Acute Coronary Syndrome, or Chest Pain.Receiving an ECG.An E/M for to a short term general, or to a Federal healthcare, and Diagnosis for AMI or an ICD-10-CM Principal or Other Diagnosis s for Angina, Acute Coronary Syndrome, or Chest Pain.Receiving an ECG Any ED patient from the 's ED Any ED patient from the 's ED Diagnosis for a (long bone) fracture.with Pain Medication as defined in the Data Dictionary.An E/M for Patients who presented to ED and signed in to be evaluated. Patients who left without being evaluated by a physician/apn/pa/residen t/intern Excluded Populations Patients who did not Patients who did not receive fibrinolytic receive fibrinolytic administration within 30 Patients for who received administration within 30 minutes and had a reason fibrinolytic administration minutes and had a reason for delay in fibrinolytic for delay in fibrinolytic therapy therapy None None Patients who expired in the ED Patients who expired in the ED Patients for whom any of the following are true:.expired in the ED.Left the emergency department against medical advice or discontinued care None Page 15

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9 Patient Safety Measure Name Heathcare Personnel Safety OP-27 Influenza vaccination coverage among healthcare personnel (single rate for inpatient and outpatient settings) Immunization (Prevention) Imm-2 Immunization for influenza Measure Description Percentage of healthcare workers given influenza vaccination Percentage of patients assessed and given influenza vaccination (inpatient) Importance/Significance 1 in 5 people in the US get influenza each season. Combined with pneumonia, influenza is the 8th leading cause of death, with two-thirds of those attributable to patients hospitalized during the flu season. Hospitalization is an underutilized opportunity to vaccinate. Improvement Noted As Data Collection Approach Data Reported To Increase in the rate (percent) (Note : Not based on claims data) National Healthcare Safety Network Website Increase in the rate (percent) QualityNet via Inpatient Data Available On Hospital Compare x MBQIP Data Reports x x FMT Reports x x Encounter Period Q4 - Q1 (Oct-Mar) Q1 (Jan 1 - Mar 31) Q2 (Apr 1 - Jun 30) Q3 (Jul 1 - Sep 30) Q4 (Oct 1 - Dec 31) Submission Period/Deadline Measure Population Sample Size Requirements 15-May NA - This measure uses administrative data and not claims to determine the measure's denominator population. No sampling - report all cases May 15 August 15 November 15 February 15 All patients discharged from acute inpatient care with a length of stay less than or equal to 120 days Reporting encouraged % of initial pt. pop % of initial pt. pop > < % of initial population % of initial pt. pop > Page 17

10 Patient Safety Data Elements Included Populations Excluded Populations Heathcare Personnel Safety OP-27 Each in a system needs to be registered separately and HCPs should be counted in the sample population for every at which s/he works. Facilities must complete a monthly reporting plan for each year or data reporting. All data reporting is aggregate (whether monthly, once a season or at a different interval). Three categories (all with separate denominators) of HCP working in the at least one day between October 1 to March 31.employees on payroll.licensed independent practitioners.students, trainees and volunteers 18yo+ A fourth optional category is available for reporting other contract personnel HCP workers who:.received vaccination at the.received vaccination outside of the.did not receive vaccination due to contraindication.did not receive vaccination due to declination None Immunization (Prevention) Imm-2.IDC-10-CM Other Diagnosis s.icd-10-pcs Other Procedure s.icd-10-cm Principal Diagnosis.IDC-10-PCS Principal Procedure.Influenza vaccination status Statement: Acute care hospitalized inpatients ages 6 months and older discharged between October 1st and March 31st. Statement: Inpatient discharges who were screened for influenza vaccine and were vaccinated prior to discharge if indicated. Patients for whom any of the following are true:.received the influenza vaccine during this inpatient hospitalization.have an ICD-10-PCS Principal Procedure or Other Procedure s for Prophylactic Vaccination against Influenza during this inpatient hospitalization.received the influenza vaccine during the current year s flu season but prior to the current hospitalization.were offered and declined the influenza vaccine.have an allergy/sensitivity to the vaccine, anaphylactic allergy to latex eggs, or for whom the vaccine is not likely to be effective because of bone marrow transplant within the past 6 months, or history of Guillain-Barre Syndrome within 6 weeks after a previous influenza vaccination Patients for whom any of the following are true:.less than 6 months of age.expired prior to hospital discharge.had an organ transplant during hospitalization.a vaccine was indicated, but supply had not been received by the hospital due to problems with vaccine production or distribution.are transferred or discharged to another acute care hospital.leave against medical advice Page 18