Minnesota Statewide Quality Reporting and Measurement System

This document is made available electronically by the Minnesota Legislative Reference Library as part of an ongoing digital archiving project. http://www.leg.state.mn.us/lrl/lrl.asp Chartbook Section 9 Minnesota Statewide Quality Reporting and Measurement System

Selected Clinic Quality Measures o Optimal Diabetes Care o o o o Optimal Vascular Care Optimal Asthma Care Adult and Child Colorectal Cancer Screening Patient Experience of Care Selected Hospital Quality Measures o Mortality for Selected Conditions o o o o Patient Safety for Selected Indicators Contents Pediatric Patient Safety for Selected Indicators Death Among Surgical Inpatients with Serious Treatable Complications Patient Experience of Care Measures List Resources A summary of the charts and graphs contained within is provided at Chartbook Summaries - Section 9. Direct links are listed on each page. Please contact the Health Economics Program at 651-201-3550 or health.hep@state.mn.us if additional assistance is needed for accessing this information. 2

CLINIC QUALITY MEASURES 3

Optimal Diabetes Care The percentage of diabetes patients, ages 18-75, who met ALL of the following five goals: 1) Blood sugar control 2) Blood pressure control 3) Cholesterol control 4) Daily aspirin use, if needed 5) No tobacco use Measure steward: MN Community Measurement National Quality Forum #0729 4

Optimal Diabetes Care, 2013 Statewide Rate 4 out of every 10 diabetic patients received optimal care Source: medhealthstore.com The 2013 statewide optimal care rate was 39%. 5

Optimal Diabetes Care, 2013 Component Rates The percentage of diabetes patients that met all five goals was 39%, however, a greater share of patients met individual goals. Patients had high rates of blood pressure control, daily aspirin use, and not using tobacco. 100% >99% 90% 84% 85% 80% 74% Percent of patients 70% 60% 50% 40% 30% 64% Statewide Optimal Rate is 39% 20% 10% 0% Blood sugar control Blood pressure control Cholesterol control Daily aspirin use No tobacco use To be included in the statewide optimal rate, patients had to meet all of the above goals. Summary of graph 6

Optimal Diabetes Care, 2011-2013 Stratified by Health Insurance Type Optimal care rates for patients with commercial insurance and Medicare were notably higher than rates for patients enrolled in MHCP and for self-pay/uninsured patients. 70% 60% 50% 2011 2012 2013 Percent of patients 40% 30% 20% 10% 0% Commercial Medicare MHCP Self-Pay/Uninsured MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and community-based waiver programs, and Medicare Savings Programs. Service year: January 1 through December 31. Summary of graph 7

Optimal Diabetes Care, 2011 and 2013 Clinic Performance In 2013, compared to 2011, the share of clinics that delivered optimal diabetes care to more than 50 percent of their patients increased by two percentage points. 30% 2011 30% 2013 25% 25% Percent of clinics 20% 15% 10% Percent of clinics 20% 15% 10% 5% 5% 0% 0% Percent of patients receiving optimal care Percent of patients receiving optimal care There were 557 reporting clinics in 2011, and 574 in 2013. Summary of graph 8

Optimal Diabetes Care, 2011 and 2013 There was little change in the number of patients receiving optimal care for diabetes between 2011 and 2013. In 2011, the statewide optimal rate was 40% and in 2013 it was 39%. 250,000 Patients 200,000 Number of patients 150,000 100,000 76,288 83,959 # of patients that received optimal care # of patients that did not receive optimal care 50,000 122,135 129,613 0 2011 2013 There were 557 reporting clinics in 2011, and 574 in 2013. Summary of graph 9

Optimal Vascular Care The percentage of ischemic vascular disease patients, ages 18-75, who met ALL the following four goals: 1) Cholesterol control 2) Blood pressure control 3) Daily aspirin use, if needed 4) No tobacco use Measure steward: MNCM NQF# 0076 10

Optimal Vascular Care, 2013 Statewide Rate 5 out of every 10 vascular patients received optimal care Source: www.theguardian.com The 2013 statewide optimal care rate was 50%. 11

100% Optimal Vascular Care, 2013 Component Rates The percentage of vascular patients that met all four goals was 50%, however, a greater share of patients met individual goals. Patients had high rates of blood pressure control, daily aspirin use and not using tobacco. 96% 90% 80% 85% 84% Percent of patients 70% 60% 50% 40% 30% 20% 10% 0% 68% Statewide Optimal Rate is 50% Blood pressure control Cholesterol control Daily aspirin use No tobacco use To be included in the statewide optimal rate, patients had to meet all of the above goals. Summary of graph 12

Optimal Vascular Care, 2011-2013 Stratified by Health Insurance Type Optimal care rates for patients with commercial insurance and Medicare were notably higher than rates for MHCP and self-pay/uninsured patients. Percent of patients 70% 60% 50% 40% 30% 20% 2011 2012 2013 10% 0% Commercial Medicare MHCP Self-Pay/Uninsured MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and community-based waiver programs, and Medicare Savings Programs. Service year: January 1 through December 31. Summary of graph 13

Optimal Vascular Care, 2011 and 2013 Clinic Performance In 2013, compared to 2011, the share of clinics that delivered optimal vascular care to more than 50 percent of their patients increased by 11 percentage points. 35% 2011 35% 2013 30% 30% Percent of clinics 25% 20% 15% 10% Percent of clinics 25% 20% 15% 10% 5% 5% 0% 0% Percent of patients who received optimal care Percent of patients who received optimal care There were 557 reporting clinics in 2011, and 570 in 2013. Summary of graph 14

Optimal Vascular Care, 2011 and 2013 There was little change in the number of patients receiving optimal care for diabetes between 2011 and 2013. In 2011 and 2013 the statewide optimal rate remained consistent at 50%. 100,000 90,000 80,000 Patients Number of patients 70,000 60,000 50,000 40,000 30,000 44,200 44,402 # of patients that received optimal care # of patients that did not receive optimal care 20,000 43,420 43,532 10,000 0 2011 2013 There were 557 reporting clinics in 2011, and 570 in 2013. Summary of graph 15

Optimal Asthma Care The percentage of adult asthma patients, ages 18-50 or 5-17, who met the ALL following three goals: 1) Asthma under control 2) Asthma at low risk of worsening 3) Asthma education received and written management plan in place Measure steward: MNCM 16

Adult Optimal Asthma Care, 2013 Statewide Rate 5 out of every 10 adult asthma patients received optimal care Source: geckohealth.tumbler.com The 2013 statewide optimal care rate was 49%. 17

100% 90% Adult Optimal Asthma Care, 2013 Component Rates The percentage of adult asthma patients that met all three goals was 49%, however, a greater share of patients met individual goals. Of all the goals, patients were most likely to be at low risk of their asthma worsening. 80% 70% 75% 68% Percent of patients 60% 50% 40% 30% 57% Statewide Optimal Rate is 49% 20% 10% 0% Under control Low risk of worsening Education and plan To be included in the statewide optimal rate, patients had to meet all of the above goals. Summary of graph 18

Adult Optimal Asthma Care, 2011-2013 Stratified by Health Insurance Type Optimal care rates for patients with commercial insurance were notably higher than rates for patients with other insurance types. 80% 70% 60% 2011 2012 2013 Percent of patients 50% 40% 30% 20% 10% 0% Commercial Medicare MHCP Self-Pay/Uninsured MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and community-based waiver programs, and Medicare Savings Programs. Service year: July 1 through June 30. Summary of graph 19

Adult Optimal Asthma Care, 2011 and 2013 Clinic Performance In 2013, compared to 2011, the share of clinics that delivered optimal asthma care to more than 50 percent of their patients increased by 21 percentage points. 2011 2013 50% 50% 40% 40% Percent of clinics 30% 20% Percent of clinics 30% 20% 10% 10% 0% 0% Percent of patients who received optimal care There were 574 reporting clinics in 2011, and 604 in 2013. Summary of graph 20 Percent of patients who received optimal care

Adult Optimal Asthma Care, 2011 and 2013 Approximately 12,000 more patients received optimal care for asthma in 2013 as compared to 2011. In 2011, the statewide optimal rate was 31% and in 2013 it was 49%. 70,000 Patients 60,000 50,000 Number of patients 40,000 30,000 16,506 28,749 # of patients that received optimal care # of patients that did not receive optimal care 20,000 10,000 36,607 30,489 0 2011 2013 There were 574 reporting clinics in 2011, and 604 in 2013. Summary of graph 21

Child Optimal Asthma Care, 2013 Statewide Rate 6 out of every 10 child asthma patients received optimal care Source: www.philly.com The 2013 statewide optimal care rate was 58%. 22

Child Optimal Asthma Care, 2013 Component Rates The percentage of child asthma patients that met all three goals was 58%, however, a greater share of patients met individual goals. Of all the goals, patients were most likely to be at low risk of their asthma worsening and have received asthma education and a management plan. 100% 90% 80% 81% 79% Percent of patients 70% 60% 50% 40% 67% Statewide Optimal Rate is 58% 30% 20% 10% 0% Under control Low risk of worsening Education and plan To be included in the statewide optimal rate, patients had to meet all of the above goals. Summary of graph 23

Child Optimal Asthma Care, 2011-2013 Stratified by Health Insurance Type Optimal care rates for patients with commercial insurance were higher than rates for all other insurance types. 2011 80% 70% 60% 2012 2013 Percent of patients 50% 40% 30% 20% 10% 0% Commercial Medicare MHCP Self-Pay/Uninsured MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and community-based waiver programs, and Medicare Savings Programs. Service year: July 1 through June 30. Summary of graph 24

Child Optimal Asthma Care, 2011 and 2013 Clinic Performance In 2013, compared to 2011, the share of clinics that delivered optimal asthma care to more than 50 percent of their patients increased by 24 percentage points. 50% 2011 50% 2013 40% 40% Percent of clinics 30% 20% 10% Percent of clinics 30% 20% 10% 0% 0% Percent of patients who received optimal care Percent of patients who received optimal care There were 530 reporting clinics in 2011, and 556 in 2013. Summary of graph 25

Child Optimal Asthma Care, 2011 and 2013 Approximately 8,500 more patients received optimal care for asthma in 2013 as compared to 2011. In 2011, the statewide optimal rate was 38% and in 2013 it was 58%. 45,000 Patients 40,000 35,000 Number of patients 30,000 25,000 20,000 15,000 14,407 22,819 # of patients that received optimal care # of patients that did not receive optimal care 10,000 22,858 16,268 5,000 0 2011 2013 There were 530 reporting clinics in 2011, and 556 in 2013. Summary of graph 26

Colorectal Cancer Screening The percentage of adult patients who are up to date with appropriate colorectal cancer screening exams, which include ANY of the following methods: 1) Colonoscopy within the measurement period or prior 9 years 2) Sigmoidoscopy within the measurement period or prior 4 years 3) Stool blood test within the measurement period Definitions. (1) Colonoscopy: An exam used to detect changes or abnormalities in the large intestine (colon) and rectum. (2) Sigmoidoscopy: An exam used to evaluate the lower part of the large intestine (colon). (3) Stool blood test: A lab test used to check stool samples for hidden blood, which may be an indicator of colon cancer or polyps in the colon or rectum. Measure steward: MNCM 27

Colorectal Cancer Screening, 2013 Statewide Rate 7 out of every 10 patients aged 50-75 were screened for Colorectal Cancer The 2013 statewide optimal care rate was 70%. Source: latestnewslink.com 28

Colorectal Cancer Screening, 2011-2013 Stratified by Health Insurance Type Optimal care rates for patients with commercial insurance and Medicare were notably higher than rates for MHCP and self-pay/uninsured patients. 100% 90% 80% 70% 2011 2012 2013 Patients 60% 50% 40% 30% 20% 10% 0% Commercial Medicare MHCP Self-Pay/Uninsured MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and community-based waiver programs, and Medicare Savings Programs. Service year: July 1 through June 30. Summary of graph 29

Colorectal Cancer Screening, 2011 and 2013 Clinic Performance In 2013, compared to 2011, the share of clinics that screened more than 50 percent of their patients for colorectal cancer increased by 2 percentage points. 40% 2011 40% 2013 35% 35% 30% 30% Percent of clinics 25% 20% 15% 10% Percent of clinics 25% 20% 15% 10% 5% 5% 0% 0% Percent of patients who received optimal care Percent of patients who received optimal care There were 568 reporting clinics in 2011, and 610 in 2013. Summary of graph 30

Colorectal Cancer Screening, 2011 and 2013 Patients Approximately 75,000 more patients were screened in 2013 as compared to 2011. In 2011, the statewide optimal rate was 68% and in 2013 it was 70%. 1,200,000 1,000,000 Number of patients 800,000 600,000 400,000 660,280 734,535 # of patients that received optimal care # of patients that did not receive optimal care 200,000 311,198 311,937 0 2011 2013 There were 568 reporting clinics in 2011, and 610 in 2013. Summary of graph 31

Patient Experience of Care The Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) 12- month Survey collects data for the following domains: 1) Access to Care 2) Provider communication 3) Office Staff 4) Provider rating Note: Clinics will use the CG-CAHPS 6-Month Survey in 2016; data will be available in 2017. Measure steward: Agency for Healthcare Research and Quality (AHRQ) NQF# 0005 32

Patient Experience of Care Domain Access to care Provider communication Description The survey asked patients how often they received: 1) appointments for care as soon as needed and 2) timely answers to questions when they called the office The survey asked patients if their doctors explained things clearly, listened carefully, showed respect, provided easy to understand instructions, knew their medical history, and spent enough time with the patient. Office staff The survey asked patients if office staff were helpful and treated them with courtesy and respect. Provider rating The survey asked patients to rate their doctors on a scale of 0 to 10, with 0 being the worst and 10 being the best. 33

Percent of Patients Who Chose the Most Positive Response to Access to Care Questions, by Number of Clinics, 2014 For the majority of clinics, 51% to 70% of patients selected the highest possible positive response when asked about getting timely appointments, care, and information. 300 268 250 Number of clinics 200 150 100 50 0 179 184 77 51 19 25 3 6 7 24-30% 31-37% 38-43% 44-50% 51-57% 58-63% 64-70% 71-77% 78-83% 84-90% Percent of most positive patient responses Summary of graph 34

Percent of Patients Who Chose the Most Positive Response to Provider Communication Questions, by Number of Clinics, 2014 For the majority of clinics, 76% to 92% of patients selected the highest possible positive response when asked how well providers communicate with patients. 300 250 251 266 Number of clinics 200 150 100 109 114 50 0 37 3 4 8 13 14 54-58% 59-62% 63-66% 67-70% 71-75% 76-79% 80-83% 84-87% 88-92% 93-96% Percent of most positive patient responses Summary of graph 35

Percent of Patients Who Chose the Most Positive Response to Office Staff Questions, by Number of Clinics, 2014 For the majority of clinics, 75% to 92% of patients selected the highest possible positive response when asked about how often office staff were helpful, courteous, and respectful. 400 350 338 300 Number of Clinics 250 200 150 100 74 220 147 50 0 1 1 2 17 17 2 45-51% 52-57% 58-63% 64-69% 70-74% 75-80% 81-86% 87-92% 93-98% 99-104% Percent of most positive patient responses Summary of graph 36

Percent of Patients Who Chose the Most Positive Response to Provider Rating Question, by Number of Clinics, 2014 For the majority of clinics, 73% to 87% of patients selected the highest possible positive response when asked to rate their doctor. 300 250 261 218 Number of Clinics 200 150 100 50 0 131 83 63 21 5 9 13 15 46-51% 52-56% 57-62% 63-67% 68-72% 73-77% 78-82% 83-87% 88-92% 93-97% Percent of most positive patient responses Summary of graph 37

HOSPITAL QUALITY MEASURES 38

Agency for Healthcare Research and AHRQ measures show: Quality (AHRQ) Measures 1. The rate expected from a hospital based on the performance of other similar hospitals around the country and 2. Whether results were significantly different from the hospital s expected performance compared to other similar hospitals around the country. Performance rates are risk adjusted to an average casemix which takes into account the severity of patient illness. AHRQ measures report whether hospitals performed better than expected (i.e., lower), the same as expected, or worse (i.e., higher) than expected considering their patient mix. Results are broken out for Prospective Payment System and Critical Access hospitals. 39

Mortality for Selected Conditions (IQI 91) This composite measure is a weighted average of the mortality indicators for patients admitted for selected conditions and is used to assess the number of deaths for the selected conditions. It includes the following indicators: Acute myocardial infarction mortality rate (IQI 15) Congestive heart failure mortality rate (IQI 16) Acute stroke mortality rate (IQI 17) Gastrointestinal hemorrhage mortality rate (IQI 18) Hip fracture mortality rate (IQI 19) Pneumonia mortality rate (IQI 20) Measure steward: AHRQ NQF# 530 40

Mortality for Selected Conditions, 2012 to 2014 Most hospitals had mortality rates as expected during 2012, 2013, and 2014. Prospective Payment System Hospitals Critical Access Hospitals Year Lower Same Higher No Results Lower Same Higher No Results 2012 16 37 0 2 0 77 1 0 2013 19 35 0 1 0 78 0 0 2014 3 49 0 3 0 78 0 0 "Lower" = Performance was better than expected Same = Performance was as expected Higher = Performance was worse than expected Service year: October 1 through September 30. 41

Patient Safety for Selected Indicators (PSI 90) This measure is a weighted average of most of the patient safety indicators and is used to assess the number of potentially preventable adverse events. It includes the following indicators: Pressure ulcer (PSI 3) Iatrogenic pneumothorax (PSI 6) Central venous catheter-related bloodstream infections (PSI 7) Postoperative hip fracture (PSI 8) Postoperative hemorrhage or hematoma (PSI 9) Postoperative physiologic and metabolic derangements (PSI 10) Postoperative respiratory failure (PSI 11) Postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT) (PSI 12) Postoperative sepsis (PSI 13) Postoperative wound dehiscence (PSI 14) Accidental puncture or laceration (PSI 15) Measure steward: AHRQ NQF# 531 42

Patient Safety for Selected Indicators, 2012 to 2014 Most hospitals had patient safety rates as expected during 2012, 2013, and 2014. Prospective Payment System Hospitals Critical Access Hospitals Year Lower Same Higher No Results Lower Same Higher No Results 2012 16 37 2 0 9 78 0 0 2013 16 38 1 0 0 78 0 0 2014 7 47 0 1 0 78 0 0 "Lower" = Performance was better than expected Same = Performance was as expected Higher = Performance was worse than expected Service year: October 1 through September 30. 43

Pediatric Patient Safety for Select Indicators (PDI 19) This composite measure is a weighted average of most of the pediatric quality indicators and is used to assess the number of potentially preventable adverse events. It includes the following indicators: Accidental puncture or laceration (PDI 1) Pressure ulcer (PDI 2) Latrogenic pneumothorax (PDI 5) Postoperative hemorrhage or hematoma (PDI 8) Postoperative respiratory failure (PDI 9) Postoperative sepsis (PDI 10) Postoperative wound dehiscence (PDI 11) Central venous catheter-related bloodstream infections (PDI 12) Measure steward: AHRQ NQF# 532 44

Pediatric Patient Safety for Select Indicators, 2012 to 2014 Most hospitals had pediatric patient rates as expected during 2012, 2013, and 2014. Prospective Payment System Hospitals Critical Access Hospitals Year Lower Same Higher No Results Lower Same Higher No Results 2012 1 54 0 0 0 66 0 12 2013 0 55 0 0 0 69 0 9 2014 0 53 2 0 0 78 0 0 "Lower" = Performance was better than expected Same = Performance was as expected Higher = Performance was worse than expected Service year: October 1 through September 30. 45

Death Among Surgical Inpatients with Serious Treatable Complications (PSI 4) This measure assesses the number of deaths per 1,000 patients having developed specified complications of care during hospitalization (e.g., pneumonia, deep vein thrombosis/pulmonary embolism, sepsis, shock/cardiac arrest, or GI hemorrhage/acute ulcer). This measure is a nursing-sensitive indicator which means it reflects the structure, process, and outcomes of nursing care. Measure steward: AHRQ NQF# 531 46

Death Among Surgical Inpatients with Serious Treatable Complications, 2012 to 2014 Most hospitals had death rates from complications as expected during 2012, 2013, and 2014. Prospective Payment System Hospitals Critical Access Hospitals Year Lower Same Higher No Results Lower Same Higher No Results 2012 6 47 0 2 0 24 1 53 2013 8 44 0 3 0 28 1 49 2014 4 45 1 5 0 31 0 47 "Lower" = Performance was better than expected Same = Performance was as expected Higher = Performance was worse than expected Service year: October 1 through September 30. 47

Hospital Patient Experience of Care The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measures patients perspectives on hospital care and covers nine topics: 1) Communication with doctors 2) Communication with nurses 3) Responsiveness of hospital staff 4) Pain management 5) Communication about medicines 6) Discharge information 7) Cleanliness of the hospital environment 8) Quietness of the hospital environment 9) Transition of care Measure steward: CMS NQF #0166 48

Percent of Patients Who Reported That Their Doctors Always Communicated Well, 2012 to 2014 Minnesota hospitals performed slightly better than the national average from 2012 to 2014. 100% 90% 80% 83% 84% 84% 81% 82% 82% Percent of patients 70% 60% 50% 40% 30% 20% 10% Minnesota National 0% 2012 2013 2014 Service year: October 1 through September 30. Summary of graph 49

Percent of Patients Who Reported That Their Nurses Always Communicated Well, 2012 to 2014 Minnesota hospitals perform slightly better than the national average from 2012 to 2014. 100% 90% 80% 80% 81% 81% 78% 79% 79% Percent of patients 70% 60% 50% 40% 30% 20% 10% Minnesota National 0% 2012 2013 2014 Service year: October 1 through September 30. Source: MDH Health Economics Program analysis of Quality Reporting System data Summary of graph 50

Percent of Patients Who Reported That Staff Always Explained About Medicines Before Giving Them, 2012 to 2014 Minnesota hospitals performed slightly better than the national average from 2012 to 2014. 100% 90% 80% Percent of patients 70% 60% 50% 40% 66% 67% 66% 64% 64% 65% Minnesota National 30% 20% 10% 0% 2012 2013 2014 Service year: October 1 through September 30. Summary of graph 51

Appendix: SQRMS MEASURES 52

2014 Reporting Year Clinic Quality Measures Measure Data Source: Medical Record Optimal Diabetes Care Optimal Vascular Care Depression Remission at 6 Months Optimal Asthma Care Adult and Child Colorectal Cancer Screening Primary C-section Rate Total Knee Replacement: Functional Status and Quality of Life Outcome Data Source: Patient Survey Patient Experience of Care Survey: Clinician and Group Consumer Assessment of Healthcare Providers and Systems 12-Month Survey Adult Data Source: Health Care Claims Healthcare Effectiveness Data and Information Set (HEDIS) measures Data Source: Clinic Survey Health Information Technology Survey Steward MNCM MNCM MNCM MNCM MNCM MNCM MNCM AHRQ NCQA MNCM/MDH Medical record data is obtained from electronic health records or paper records. A Measure Steward is an organization that owns and is responsible for maintaining the measure. Measure stewards are often the same as measure developers, but not always. Source: Quality Reporting System, 2014. 53

2015 Reporting Year Hospital Quality Measures Measure Steward Hospital Type Data Source: Medical Record Acute myocardial infarction: Fibrinolytic therapy received within 30 minutes of hospital arrival (AMI-7a) Surgical care improvement project: Cardiac surgery patients with controlled postoperative blood glucose (SCIP-Inf-4) CMS CMS PPS hospitals, voluntary for CAHs PPS and CAHs Influenza immunization: Influenza immunization (IMM-2) CMS PPS and CAHs Emergency Department Measures Median time from ED arrival to ED departure for admitted ED patients - Overall rate (ED-1a) Admit decision time to ED departure time for admitted patients - Overall rate (ED-2a) CMS PPS hospitals, voluntary for CAHs Elective delivery (PC-01) CMS PPS and CAHs Outpatient acute myocardial infarction and chest pain Fibrinolytic therapy received within 30 minutes of emergency department arrival (OP-2) Median time to transfer to another facility for acute coronary intervention (OP-3) Aspirin at arrival (OP-4) Median time to ECG (OP-5) CMS PPS and CAHs Medical record data is obtained from electronic health records or paper records. A Measure Steward is an organization that owns and is responsible for maintaining the measure. Measure stewards are often the same as measure developers, but not always. Source: Quality Reporting System, 2015. 54

2015 Reporting Year Hospital Quality Measures Measure Data Source: Medical Record Emergency department stroke registry indicators Door-to-imaging initiated time Time to intravenous thrombolytic therapy Emergency department transfer communication Late sepsis or meningitis in very low birth weight neonates Central line-associated bloodstream infection event by inpatient hospital unit for hospitals with a neonatal intensive care unit and/or pediatric intensive care unit Data Source: Patient Survey Patient experience of care Steward Minnesota Stroke Registry Program American Heart Association/ American Stroke Association University of Minnesota Rural Health Research Center Vermont Oxford Network Centers for Disease Control and Prevention CMS Hospital Type PPS and CAHs CAHs only PPS and CAHs PPS and CAHs PPS and CAHs 55

2015 Reporting Year Hospital Quality Measures Measure Data Source: Health Care Claims Mortality Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following acute myocardial infarction hospitalization (MORT-30-AMI) Hospital 30-day, all-cause, RSMR following heart failure hospitalization (MORT-30-HF) Hospital 30-day, all-cause, RSMR following pneumonia hospitalization (MORT-30-PN) Mortality for selected conditions composite (IQI 91) Death among surgical inpatients with serious treatable complications (PSI 4) Obstetric trauma- vaginal delivery with instruments (PSI 18) Obstetric trauma - vaginal delivery without instrument (PSI 19) Patient safety for selected indicators composite (PSI 90) Pediatric heart surgery mortality (PDI 6) Pediatric heart surgery volume (PDI 7) Pediatric patient safety for selected indicators composite (PDI 19) Data Source: Hospital Survey Health Information Technology Survey Steward CMS AHRQ AHRQ AHRQ AHRQ AHRQ AHRQ AHRQ AHRQ American Hospital Association/ MDH Hospital Type PPS and CAHs PPS and CAHs PPS and CAHs 56

RESOURCES 57

Additional Information from the Health Economics Program Available Online Health Economics Program www.health.state.mn.us/divs/hpsc/hep/index.html Publications www.health.state.mn.us/divs/hpsc/hep/publications/index.html Health Care Markets Chartbook www.health.state.mn.us/divs/hpsc/hep/chartbook/index.html Statewide Quality Reporting and Measurement System www.health.state.mn.us/healthreform/measurement 58

Quality Measurement Resources MN Community Measurement (MNCM) and HealthScores mncm.org www.mnhealthscores.org Stratis Health www.stratishealth.org Minnesota Hospital Association (MHA) www.mnhospitals.org Hospital Compare www.medicare.gov/hospitalcompare/search.html National Quality Forum (NQF) www.qualityforum.org www.qualityforum.org/qps/qpstool.aspx Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov www.cahps.ahrq.gov 59