Iowa Healthcare Collaborative - HEN 2.0 Measures Yellow Pink Purple Green Blue Legend Readmissions and Care Transitions Healthcare-associated Infections Hospital Acquired Conditions Safety Across the Board Leading Edge Advanced Practice Topics (LEAPT) READMISSIONS AND CARE TRANSITIONS Category Measure Measure Type Numerator Description Denominator Description Data Source Readmissions Unplanned All-Cause, 30-Day Readmissions Number of Acute Care inpatient discharges that meet criteria for all-cause, 30-day, allpayer readmission Number of Acute Care Inpatient discharges meeting eligibility for inclusion as an index admission Community Involvement in Identifying Post- Discharge Needs Process Number of discharges for Acute Care, Skilled Facility and Swing Bed inpatient discharges Nursing Care and Swing Bed inpatient where community providers (e.g. home care, discharges primary care, nurses, skilled nursing) were included in assessing post discharge needs Post-Hospital Follow-Up Appointment Process Facility and Swing Bed inpatient discharges with follow-up appointment scheduled before discharge in accordance with risk assessment Patient Teach-Back Process Number of observations of nurses where teach-back is used to assess understanding Timely Handover Communication Process Facility and Swing Bed inpatient discharges where critical information is transmitted to the next site of care (e.g. office, LTC, HH) or person continuing care *ED Transfer Communication (MBQIP Phase 3) Process another healthcare facility where all elements were communicated to the receiving facility Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges Number of observations of nurse teaching Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges ** another healthcare facility (Hospice- Healthcare Facility, Acute Care Facility (CAH/General Inpatient Care/Cancer/Children's/VA) 1
READMISSIONS AND CARE TRANSITIONS Category Measure Measure Type Numerator Description Denominator Description Data Source Readmissions *ED Transfer Communication (MBQIP Phase 3) another healthcare facility where all Administatrive Communication (Nurse-to- Nurse and Physician-to-Physician information) was communicated another healthcare facility where all Patient Information (name, address, age, gender, contact, insurance info) was communicated another healthcare facility where all Vital Signs (pulse, resp rate, blood pressure, oxygen sat, temperature, Glasgow Coma Scale neuro assessment) was communicated another healthcare facility where Medication Information (meds administered in ED, allergies and home meds) was communicated another healthcare facility where all Pactitioner-Generated Information (history & physical, reason for transfer and plan of care) was communicated another healthcare facility where all the Nurse-Generated Information (nursing assessments, interventions, response, sensory status, catheters, immobilizations, resp support and oral limitations)was communicated another healthcare facility where all Procedures and Tests done and all Procedure and Test results were communicated 2
HEALTHCARE-ASSOCIATED INFECTIONS Category Measure Measure Type Numerator Description Denominator Description Data Source Catheter-Associated Urinary Tract Infection Rate Number of hospital-acquired urinary tract infections Number of Acute Care inpatient urinary catheter days Catheter-Associated Urinary Tract Infection Central Line Associated Blood Stream Infection Surgical Site Infection Unnecessary Urinary Catheters Process Facility and Swing Bed inpatients with new Facility and Swing Bed inpatients with new indwelling urinary catheters inserted without indwelling urinary catheter insertions appropriate indication documented Emergency Department Catheter Utilization Process Number of Emergency Department urinary catheter insertions Urinary Catheter Utilization Ratio Process Facility and Swing Bed inpatient days with urinary catheter in place Central Line-Associated Bloodstream Infection Rate Number of hospital-acquired, central lineassociated bloodstream infections for the patients in the denominator population per NHSN guidelines Central Line Insertion Compliance Process Facility and Swing Bed inpatients with full PICC line and/or central line catheter insertion bundle compliance Number of Emergency Department visits Facility and Swing Bed inpatient days Number of Acute Care inpatient central line catheter days Facility and Swing Bed inpatients with PICC line and/or central line insertions Statewide Outpatient Database (SOD) Central Line Utilization Ratio Process Number of central line days Total number of patient days Colon Surgical Site Infection Rate Number of hospital-acquired colon surgical Number colon surgical episodes site infections in the denominator population per NHSN guidelines Abdominal Hysterectomy Surgical Site Infection Rate Number of hospital-acquired abdominal hysterectomy surgical site infections Hip Replacement Surgical Site Infection Rate Number of hospital-acquired hip replacement surgical site infections Knee Replacement Surgical Site Infection Rate Number of hospital-acquired knee replacement surgical site infections Surgery Patients With Perioperative Temperature Management Process Number of surgical inpatients for whom either active warming was used intraoperatively or who had at least one body temperature equal to or greater than 96.8F/36C within 30 minutes immediately prior to or 15 minutes immediately after anesthesia end time Surgical Safety Checklist Compliance Process Number of days in the month in which the checklist was used in all cases Number abdominal hysterectomy surgical episodes Number hip replacement surgical episodes Number knee replacement surgical episodes Number of surgery patients undergoing procedure under general or neuraxial anesthesia of greater than or equal to 60 minutes duration Number of operating room days in the month 3
HEALTHCARE-ASSOCIATED INFECTIONS Category Measure Measure Type Numerator Description Denominator Description Data Source Ventilator-Associated Events Ventilator-Associated Condition (VAC) Number of events that meet VAC criteria Number of ventilator days Infection-Related Ventilator-Associated Complication (IVAC) Possible/Probable Ventilator-Associated Pneumonia Number of events that meet IVAC criteria Number of ventilator days Number of events that meet possible/probable criteria Ventilator Bundle Compliance Process Number of ICU inpatients on mechanical ventilation with full vent-associated prevention bundle compliance Number of ventilator days Number of ICU patients on mechanical ventilation on day of week sample For each focus area, select at least one outcome measure and at least one process measure. Where data source is other than self-reported, ensure submission to alternate source. All NHSN data sources must be reported to CDC/NHSN. Be sure to confer rights to IHC. Must report meaningful data - no 0 denominators allowed for self-reported measures. Work with person(s) in your facilities on timely submission of SID data to receive monthly updates. 4
HOSPITAL ACQUIRED CONDITIONS Adverse Drug Events Adverse Drug Event Rate Facility, Swing Bed or Observation adverse drug events Facility, Swing Bed and Observation patient days Adverse Drug Events Originating During Hospital Stay (AHRQ) Number of Acute Care adverse drug events that cause harm *Documented INRs Greater Than 5 Process Number of lab measurements for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients on Warfarin where documented INR >5 *Stat Narcan Administered Process Number of episodes when a reversal agent (e.g. naloxone) is administered to Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients prescribed opioids *Blood Glucose Less Than 50 Process Number of blood glucose measurements (per lab reports, POCT, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients where blood glucose <50 **Documented INRs Greater Than 5 (Pediatric) Process Number of lab measurements for Distinct Unit Pediatric patients on Warfarin where documented INR >5 **Stat Narcan Administered (Pediatric) Process Number of episodes when a reversal agent (e.g. naloxone) is administered to Distinct Unit Pediatric patients prescribed opioids **Blood Glucose Less Than 50 (Pediatric) Process Number of blood glucose measurements (per lab reports, POCT, EMR, Charge Data, etc.) for Distinct Unit Pediatric patients where blood glucose <50 ***CPOE Medication Order Pharmacist Verification Process Number of electronically entered med orders (CPOE) for Acute Care inpatients that are verified by a pharmacist or directly entered by a pharmacist within 24 hours *ADE process measures for blood glucose, INR and opioids are REQUIRED. **Hospitals with distinct unit pediatrics must report ADE process measures in addition to housewide measures. ***MBQIP Phase 3 measure CPOE Order Verification results will serve to meet Flex Program requirement for reporting. Must report meaningful data - no 0 denominators allowed for self-reported measures. Number of Acute Care discharges Number of INR lab measurements for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients on Warfarin prescribed opioids Number of blood glucose measurements (per lab reports/poct, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Care, Swing Bed and Observation patients Number of INR lab measurements for Distinct Unit Pediatric patients on Warfarin Number of Distinct Unit Pediatric patients prescribed opioids Number of blood glucose measurements (per lab reports/poct, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Care, Swing Bed and Observation patients Number of electronically entered medication orders (CPOE) for Acute Care inpatients 5
HOSPITAL ACQUIRED CONDITIONS (cont) Falls & Immobility Fall Resulting in Fracture or Dislocation (CMS) Number of Acute Care inpatient discharges with ICD-9/10 fracture or dislocation code(s) Number of Acute Care discharges Fall Resulting in No Apparent Injury Number of falls for Acute Care, Skilled Nursing Facility, Swing Bed and Observation Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and patients that have unplanned descent to the Observation patient days - exclude newborn floor resulting in no visible sign of injury, and respite patients stable vital signs and patient denial or pain or discomfort Fall Resulting in Minor Injury Number of for Acute Care, Skilled Nursing that have unplanned descent to the floor resulting in minor cuts, minor bleeding, minor skin abrasions, minor swelling and minor contusions or bruising Fall Resulting in Moderate Injury Number of for Acute Care, Skilled Nursing that have unplanned descent to the floor resulting in excessive bleeding, lacerations requiring sutures, temporary loss of consciousness or moderate head trauma Fall Resulting in Major Injury Number of for Acute Care, Skilled Nursing that have unplanned descent to the floor resulting in fracture, subdural hematoma, other major head trauma, cardiac arrest or patient requiring transfer to ICU or OR Fall Resulting in Death Rate Number of for Acute Care, Skilled Nursing that have unplanned descent to the floor resulting in death Count of Assisted Falls Number of Acute Care, SNF, Swing Bed and Observation patients with events where the patient is assisted or eased to the floor Fall Risk Assessed on Admission Process assessed for fall risk on admission admitted 6
HOSPITAL ACQUIRED CONDITIONS (cont) Obstetrical Adverse Events Early Elective Delivery Number of elective maternal deliveries between 37-39 weeks gestation with no medical indication All deliveries between 37-39 weeks gestation Primary Cesarean Delivery Rate, Uncomplicated (AHRQ PSI 3) Peripartum Hysterectomy in Women With Placenta Previa Peripartum Hysterectomy in Women Without Placenta Previa Birth Trauma Rate - Injury to Newborn (AHRQ PSI 17) OB Trauma, Vaginal Deliveries With Instrument (AHRQ PSI 18) OB Trauma, Vaginal Deliveries Without Instrument (AHRQ PSI 19) Number of maternal inpatients with either MS-DRG code for Cesarean delivery or anylisted ICD-9/10 procedure code(s) for Cesarean delivery without any-listed ICD- 9/10 procedure code(s) for hysterotomy Number of deliveries Number of peripartum hysterectomies in Number of deliveries women with placenta previa and/or placenta accreta/percreta Number of peripartum hysterectomies in Number of deliveries women without placenta previa and/or placenta accreta/percreta Number of Newborns with ICD-9/ICD-10 Number of Newborns code(s) for birth trauma Number of vaginally-delivering, instrumentassisted Moms with ICD-9/ICD-10 code(s) for procedure code(s) for instrument-assisted Number of vaginal deliveries with ICD-9 3rd or 4th degree obstetric trauma delivery Number of vaginally-delivering, non instrument-assisted Moms with ICD-9/ICD- 10 code(s) for 3rd or 4th degree obstetric trauma Obstetrical Trauma Composite Number of delivered maternal inpatients with one or more adverse events Risk Assessment for Maternal Hemorrhage Process Number of maternal inpatients with documented risk assessment for maternal hemorrhage completed on admission Timely Treatment for Severe Hypertension Process Number of pregnant women who are treated within 60 minutes with first-line medications (IV labetalol or IV hydralazine or PO nifedipine if IV access has not been established) Number of vaginal deliveries without ICD-9 procedure code(s) for instrument-assisted delivery Number of deliveries Number of maternal inpatients who have given birth at or greater than 20 weeks completed gestation Number of women giving birth 20 weeks gestation with a diagnosis of severe preeclampsia or preeclampsia superimposed on pre-existing hypertension AND who had severe hypertension 7
HOSPITAL ACQUIRED CONDITIONS (cont) Pressure Ulcers Stage III, IV or Unstageable Pressure Ulcers (AHRQ and PSI 3) Facility and Swing Bed inpatients with ICD- 9/10 code(s) for pressure ulcer AND secondary ICD-9/10 diagnosis code(s) for Stage III, Stage IV or unstageable pressure ulcer, non-poa Swing Bed inpatient discharges Venous Thromboembolism At-Risk Patients Receiving Full Pressure Ulcer Preventive Care Post-Operative Pulmonary Embolism or Deep Venous Thrombosis (AHRQ PSI 12) Process Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients receiving full pressure ulcer preventative care Number of Acute Care surgical inpatients with non-poa secondary ICD-9/10 code(s) for DVT or PE VTE Appropriate Prophylaxis Process identified as at risk for VTE who received appropriate prophylaxis or have documentation why no VTE prophylaxis was given Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients Number of Acute Care surgical inpatient discharges Number of admissions to Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients with stays of >48 hours For each focus area (except ADE), select at least one outcome measure and at least one process measure. Where data source is other than self-reported, ensure submission to alternate source. Must report meaningful data - no 0 denominators allowed for self-reported measures. Work with person(s) in your facilities on timely submission of SID data to receive monthly updates. 8
SAFETY ACROSS THE BOARD Safety Across the Weighed Average of Observed-to-Expected Ratios Weighted Average of the Reliability-Adjusted Observed-to-Expected Ratios for component Board for Selected AHRQ PSIs (AHRQ PSI 90) indicators: PSI 03, 06, 07, 08, 09, 10, 11, 12, 13, 14, 15 Death Rate Among Surgical Inpatients With Serious Treatable Complications (AHRQ PSI 4) Work with person(s) in your facilities on timely submission of SID data to receive monthly updates. Number of Acute Care surgical inpatient deaths Number of Acute Care surgical discharges LEADING EDGE ADVANCED PRACTICE TOPICS (LEAPT) Clostridium Difficile Hospital-Acquired Clostridium Difficile Risk-adjusted C. diff rate that compares the observed number of infections to the expected number of infections for selected units based on NHSN aggregate data Hospital-Acquired Clostridium Difficile Number of hospital onset and community acquired Clostridium difficile infections Number of Acute Care inpatient days Hand Hygiene Compliance Process Number of observations where appropriate hand-washing technique was applied Number of observations Sepsis Worker Safety Undue Exposure to Radiation Postoperative Sepsis Rate (AHRQ) Number of Acute Care elective surgical Number of Acute Care elective surgical inpatient discharges with any secondary ICD- inpatient discharges with any-listed ICD-9/10 9/10 diagnosis code for sepsis procedure code for an operating room procedure Sepsis Rate Number of Acute Care inpatients with any secondary ICD-9/10 diagnosis code for sepsis, not POA Severe Sepsis and Septic Shock Management Bundle Compliance (NQF) Process Facility and Swing Bed inpatients presenting with severe shock or septic shock who receive assessment per Severe Sepsis and Septic Shock Management Bundle within 3- hours Number of Acute Care inpatient discharges Facility and Swing Bed inpatients presenting with severe shock or septic shock Work-Related Back Injuries Number of work-related back injuries Number of FTEs Needlesticks Number of needlestick events Number of FTEs Safe Patient Handling Program Equipment Checklist Compliance Process Number of units with all checklist items 'In Place.' Number of units assessed Abdomen CT - Use of Contrast Material (CMS) Number of outpatient abdomen CT studies with and without contrast ('combined studies') Thorax CT - Use of Contrast Material (CMS) Number of outpatient thorax CT studies with and without contrast ('combined studies') Total CT Dose Capture Compliance - DLP Process Total number of CTs in which the total DLP is recorded Total CT Dose Capture Compliance - CTDIvol Process Total number of CTs in which the total CTDIvol is recorded Total CT Dose Capture Compliance - SSDE Process Total number of CTs in which the total SSDE is recorded Number of outpatient abdomen CT studies performed (with, without OR both with and without contrast) Number of outpatient thorax CT studies performed (with, without or both with and without contrast) Total number of CTs Total number of CTs Total number of CTs Statewide Inpatient/Outpatient Database (SID/SOD) Statewide Inpatient/Outpatient Database (SID/SOD) 9
For each focus area, select at least one outcome measure and at least one process measure. Where data source is other than self-reported, ensure submission to alternate source. Must report meaningful data - no 0 denominators allowed for self-reported measures. Work with person(s) in your facilities on timely submission of SID data to receive monthly updates. 10