K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals AEA Minimum Participation Full Participation 1, 2

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1 Outcome Measure for Any One of the Following: Outcome Measures Meeting Either A or B: Adverse Drug Events (ADE) All measures are surveillance data Hospital Collected Anticoagulant (ADE-12) Opioid (ADE-111) Glucose Control (ADE-13) An overall measure of ADEs (ADE-112) Outcome Measure Meeting A or B: A) Related to all three of: anticoagulant, opioid, and glucose control B) Related to two of anticoagulant, opioid, and glucose control A measure of overall ADEs or a different highfrequency ADE Outcome Measures Meeting A and one of B: Catheter-Associated Urinary Tract Infection (CAUTI) A) NHSN/NDNQI CAUTI Rate (ICU) (CAUTI-19) B) NHSN/NDNQI CAUTI Rate (All units) (CAUTI-18) Surveillance data unless hospital is entering all of these procedures in NHSN A) NHSN/NDNQI CAUTI Rate including both: ICU/NICU (CAUTI-19) General units (including specialty units) measured separately and/or combined (CAUTI- 18) Surveillance data unless hospital is entering all of these procedures in NHSN B) A catheter utilization measure A utilization ratio (catheter days per patient days) (CAUTI-113) ED Catheterization rate (CAUTI-115) 1

2 Outcome Measure: Central Line Associated Blood Stream Infection (CLABSI) NHSN/NDNQI CLABSI Rate ICU/NICU only (CLABSI-25) Days since last CLABSI (CLABSI-TBD) A) NHSN/NDNQI CLABSI Rate including all: ICU/NICU (CLABSI-25) General units (including specialty units) measured separately and/or combined (CLABSI- 24) B) For larger hospitals, a utilization ratio (central line days per patient days) (CLABSI-122) C) Other HEN-defined measure that applies to small hospitals (<100 beds) (e.g., days since last CLABSI) (CLABSI-TBD) Note: For larger hospitals, measurement of housewide CLABSI rate may use an alternative specification, such as a measure with denominator of patient days. At least one outcome measure meeting either A or B: Falls Obstetrical Early Elective Deliveries (OB-EED) All falls with or without Injury (FALLS-37) Outcome Measure Meeting A: A) Joint Commission PC-01 A) All falls (FALLS-37) Injuries from Falls and Trauma (MCR FFS CMS HAC) (FALLS-39 Claims Based) B) All falls with injury (not limited to subset of patients with severe injuries) (FALLS-38) Outcome Measure Meeting A: B) Joint Commission PC-01 2

3 Outcome Measures Meeting A or B: Other Obstetrical (OB-Other) A) At least two of: AHRQ PSIs 17 (OB-48), 18 (OB-54), and 19 3 (OB-55) (AHRQ data) B) Reporting Obstetrical hemorrhage (OB-118) and preeclampsia treatment and management to prevent morbidity and mortality (OB-120) A) At least two of: AHRQ PSIs 17 (OB-48), 18 (OB-54), and 19 (OB-55) (AHRQ data) B) Reporting Obstetrical hemorrhage (OB-118) and preeclampsia treatment and management to prevent morbidity and mortality (OB-120) Pressure Ulcers (PrU) Surgical Site Infections (SSI) Stage 3 and higher PrUs (PrU-63 or 61) (Claims based and AHRQ) Outcomes Measures for 2 or More of the Following (separately or combined ) (SSI-89): Colon Hysterectomy Knee Replacement Hip Replacement Cardiac Surgeries (may be specific to a common subset of cardiac surgeries such as Coronary Artery Bypass Graft [CABG]) Stage 2 and higher PrUs (PrU-58) Stage 3 and higher PrUs (PrU-63 and 61) (Claims based and AHRQ) Outcomes Measures for 4 or More of the Following (separately or combined) (SSI-89): Colon Hysterectomy Knee Replacement Hip Replacement Cardiac Surgeries (may be specific to a common subset of cardiac surgeries such as CABG) Surveillance data unless hospital is entering all of these procedures in NHSN 3

4 Outcome Measures: Readmissions Only diagnosis-specific readmission rates: A) HF Readmissions within 30 Days (All cause) (READ-77) A) Broad measure: 30-day all payer all cause readmissions (READ- 75) B) HEN indicates if measure counts only readmissions to the hospital of the index admission or to any hospital; and any exclusions (e.g. planned readmissions) used Outcome Measure Meeting A or B: Ventilator-Associated Events (VAE) Adults Only A) NHSN-defined Ventilator-acquired conditions (VACs) alone ( respiratory status component ) (ICU Only or All Units) (VAE-96a or 96d) B) At least one of: Infection-related Ventilator-Associated Complication (IVACs) ( infection/ inflammation component ) (ICU Only or All Units) (VAE-96b or 96e) Possible or Probable VAP (ICU Only or All Units) (VAE-96c or 96f) Surveillance data unless hospital is entering all of these procedures in NHSN A) NHSN-defined Ventilator-acquired conditions (VACs) alone ( respiratory status component ) (ICU Only and All Units) (VAE-96a or 96d) C) At least one of: Infection-related Ventilator-Associated Complication (IVACs) ( infection/ inflammation component ) (ICU Only or All Units) (VAE-96b or 96e) Possible or Probable VAP (ICU Only or All Units) (VAE-96c or 96f) Surveillance data unless hospital is entering all of these procedures in NHSN 4

5 Outcome Measure meeting either A or B: Venous Thromboembolism (VTE) A) AHRQ PSI-12 (VTE-105) (AHRQ) B) Potentially preventable VTE Rate (meaningful use or CMS definition, VTE-6) (VTE-104) A) AHRQ PSI-12 (VTE-105) (AHRQ) B) Potentially preventable VTE Rate (meaningful use or CMS definition, VTE-6) (VTE-104) 1 Includes either submission or attestation that at least one corresponding process measure is being collected per AEA with the exception of EED which is a required process measure for birthing hospitals 2 K-HEN collected measures are listed in RED. Please note the information pertaining to NHSN. 3 PSI 17 Birth Trauma Rate Injury to Neonate; PSI 18 Obstetric Trauma Rate Vaginal Delivery With Instrument; PSI 19 Obstetric Trauma Rate Vaginal Delivery without Instrument 4 NHSN data is only available to K-HEN if you are entering the specified data in NHSN and you have conferred rights to the KHA Quality group 5