The Iowa Healthcare Collaborative - HEN Measure Descriptions 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 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 Facility and Swing Bed inpatient discharges with follow-up appointment scheduled before discharge in accordance with risk assessment Patient Teach-Back Number of observations of nurses where teach-back is used to assess understanding Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges Number of observations of nurse teaching Timely Handover Communication 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) Administrative Communication [NEW record documents indicate that all Nurse-to- Nurse Communication and Physician-to- Physician Communication were communicated 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 *ED Transfer Communication (cont) Patient Information [NEW Vital Signs [NEW Medication Information [NEW record documents indicate that Name, Address, Age, Gender, Significant Other Contact Info and Insurance information were communicated record documents indicate that Pulse, Respiratory Rate, Blood Pressure, Oxygen Saturation, Temperature and Glascow Coma Scale/Neuro Assessment were communicated record documents indicate that Medications Administered in ED, Allergies and Home Medications were communicated ** another healthcare facility (Hospice- Healthcare Facility, Acute Care Facility (CAH/General Inpatient Care/Cancer/Children's/VA) Physician or Practitioner Generated Information [NEW Nurse Generated Information [NEW Procedures and Tests [NEW record documents indicate that History and Physical and Reason for Transfer/Plan of Care were communicated record documents indicate that Nursing Assessments/Interventions/Response, Sensory Status, Catheters, Immobilizations, Respiratory Support and Oral Limitations were communicated record documents indicate that Tests and Procedures Done and Tests and Procedure Results Sent were communicated All Readmission process measures are recommended but must select at least one. *MBQIP Phase 3 measure ED Transfer Communication results will serve to meet Flex Program requirement for reporting. **Denominator for MBQIP Phase 3 measure ED Transfer Communication must be 45 or less - sample if necessary. 2
HEALTHCARE-ASSOCIATED INFECTIONS Category Measure Measure Type Numerator Description Denominator Description Data Source Catheter-Associated Urinary Tract CAUTI SIR - ICU [NEW Risk-adjusted CAUTI rate that compares the observed number of infections to the expected number of infections for ICU units excluding NICU Infection CAUTI SIR - ICU and Other Units [NEW Risk-adjusted CAUTI rate that compares the observed number of infections to the expected number of infections for the ICU units plus other units Central Line Associated Blood Stream Infection Surgical Site Infection Unnecessary Urinary Catheters Facility and Swing Bed inpatients with new indwelling urinary catheters inserted without appropriate indication documented Emergency Department Catheter Utilization Number of Emergency Department urinary catheter insertions Urinary Catheter Utilization Ratio Facility and Swing Bed inpatient days with urinary catheter in place Facility and Swing Bed inpatients with new indwelling urinary catheter insertion Facility or Swing Bed inpatients admitted through the Emergency Department Facility and Swing Bed inpatient days Statewide Outpatient Database (SOD) CLABSI SIR - ICU [NEW Risk-adjusted CLABSI rate that compares the observed number of infections to the expected number of infections for ICU units excluding NICU CLABSI SIR - ICU and Other Units [NEW Central Line Insertion Compliance Facility and Swing Bed inpatients with full PICC line and/or central line catheter insertion bundle compliance Facility and Swing Bed inpatients with PICC line and/or central line insertions Central Line Utilization Ratio Number of central line days Total number of patient days ACS-CDC Harmonized Procedure-Specific SSI - Colon [NEW ACS-CDC Harmonized Procedure-Specific SSI - Abdominal Hysterectomy [NEW ACS-CDC Harmonized Procedure-Specific SSI - Total Hip [NEW ACS-CDC Harmonized Procedure-Specific SSI - Total Knee [NEW Surgery Patients With Perioperative Temperature Management [NEW Surgical Safety Checklist Compliance [NEW Risk-adjusted CLABSI rate that compares the observed number of infections to the expected number of infections for the ICU units plus other units Risk-adjusted Colon SSI rate that compares the observed number of infections to the expected number of infections Risk-adjusted Abdominal Hysterectomy SSI rate that compares the observed number of infections to the expected number of infections Risk-adjusted Total Hip SSI rate that compares the observed number of infections to the expected number of infections Risk-adjusted Total Knee SSI rate that compares the observed number of infections to the expected number of infections 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 Number of days in the month in which the checklist was used in all cases 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 (cont) Category Measure Measure Type Numerator Description Denominator Description Data Source Ventilator-Associated Ventilator-Associated Condition (VAC) Events 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 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. 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 Number of lab measurements for Acute Observation patients on Warfarin where documented INR >5 *Stat Narcan Administered Number of episodes when a reversal agent (e.g. naloxone) is administered to Acute Observation patients prescribed opioids *Blood Glucose Less Than 50 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) [NEW **Stat Narcan Administered (Pediatric) [NEW Number of lab measurements for Acute Observation patients on Warfarin where documented INR >5 Number of episodes when a reversal agent (e.g. naloxone) is administered to Acute Observation patients prescribed opioids Number of Acute Care discharges Number of INR lab measurements for Acute 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 Acute Observation patients on Warfarin Facility, Swing Bed and Observation patients prescribed opioids **Blood Glucose Less Than 50 (Pediatric) [NEW 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 Number of blood glucose measurements (per lab reports/poct, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Care, Swing Bed and Observation patients ***CPOE Medication Order Pharmacist Verification (MBQIP Phase 3) [NEW Number of electronically entered med Number of electronically entered orders (CPOE) for Acute Care inpatients that medication orders (CPOE) for Acute Care are verified by a pharmacist or directly inpatients 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. 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 patients that have unplanned descent to the floor resulting in no visible sign of injury, 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 Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients 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 falls for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients with no apparent injury - exclude newborn and respite patients Fall Risk Assessed on Admission assessed for fall risk on admission admitted 6
HOSPITAL ACQUIRED CONDITIONS (cont) Pressure Ulcers Stage III, IV or Unstageable Pressure Ulcer (AHRQ) 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 Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients (refer to AHRQ PSI 3 technical specifications for exclusions) At-Risk Patients Receiving Full Pressure Ulcer Preventive Care Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients receiving full pressure ulcer preventative care Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed inpatients Obstetrical Adverse Events Early Elective Delivery (CMS) Number of elective maternal deliveries between 37-39 weeks gestation with no medical indication Primary Cesarean Delivery Rate, Uncomplicated (AHRQ) Peripartum Hysterectomy in Women With Placenta Previa Peripartum Hysterectomy in Women Without Placenta Previa 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 peripartum hysterectomies in women with placenta previa and/or placenta accreta/percreta Number of peripartum hysterectomies in women without placenta previa and/or placenta accreta/percreta Birth Trauma Rate - Injury to Newborn (AHRQ) Number of Newborns with ICD-9/ICD-10 code(s) for birth trauma OB Trauma, Vaginal Deliveries With Instrument (AHRQ) OB Trauma, Vaginal Deliveries Without Instrument (AHRQ) Number of vaginally-delivering, instrumentassisted Moms with ICD-9/ICD-10 code(s) for 3rd or 4th degree obstetric trauma 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 [NEW Number of maternal inpatients with documented risk assessment for maternal hemorrhage completed on admission All deliveries between 37-39 weeks gestation Number of non-preterm deliveries without previous Cesarean section, abnormal presentation (breech), fetal death or multiple gestation Number of deliveries Number of deliveries Number of Newborns excluding preterm infants with birth weight less than 2000 grams, injury to brachial plexus or osteogenesis imperfecta Number of vaginal deliveries with ICD-9 procedure code(s) for instrument-assisted delivery Number of vaginal deliveries without ICD-9 procedure code(s) for instrument-assisted delivery Number of deliveries Number of maternal inpatients who have gave birth at or greater than 20 weeks completed gestation 7
HOSPITAL ACQUIRED CONDITIONS (cont) Obstetrical Adverse Events (cont) Timely Treatment for Severe Hypertension [NEW Venous Thromboembolism Post-Operative Pulmonary Embolism or Deep Venous Thrombosis (AHRQ) Number of maternal inpatients 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 Acute Care surgical inpatients with non-poa secondary ICD-9/10 code(s) for DVT or PE VTE Appropriate Prophylaxis (CMS) identified as at risk for VTE who received appropriate prophylaxis or have documentation why no VTE prophylaxis was given Number of maternal inpatients 20 weeks gestation giving birth with a diagnosis of severe preeclampsia or preeclampsia superimposed on pre-existing hypertension AND who had severe hypertension Number of Acute Care surgical inpatient discharges excluding cases where DVT/PE are present on admission, where a procedure for interruption of vena cava occurs before or on the same day or any procedure for extracorporeal membrane oxygenation 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. 8
SAFETY ACROSS THE BOARD Safety Across the Patient Safety Indicator 90 (AHRQ) Weighted Average of the Reliability-Adjusted Observed-to-Expected Ratios for component Board indicators: PSI 03, 06, 07, 08, 09, 10, 11, 12, 13, 14, 15 Death Rate Among Surgical Inpatients With Serious Number of Acute Care surgical inpatient Number of Acute Care surgical discharges Treatable Complications (AHRQ) deaths LEADING EDGE ADVANCED PRACTICE TOPICS (LEAPT) Clostridium Difficile Hospital-Acquired Clostridium Difficile [NEW 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 Hand Hygiene Compliance [NEW Number of observations where appropriate Number of observations hand-washing technique was applied Sepsis Worker Safety Postoperative Sepsis Rate (AHRQ) [NEW Sepsis Rate [NEW 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) [NEW 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 diagnosis code for sepsis 9/10 procedure code for an operating room procedure Number of Acute Care inpatient discharges Facility and Swing Bed inpatients presenting Facility and Swing Bed inpatients presenting with severe shock or septic shock who with severe shock or septic shock receive assessment per Severe Sepsis and Septic Shock Management Bundle within 3- hours Work-Related Back Injuries [NEW Number of work-related back injuries Number of FTEs Needle Safety [NEW Number of needlestick events Number of FTEs Education/Training Completed by Direct Care Providers on Recommended Practices/Techniques [NEW Number of direct care providers who complete all recommended practice/technique education and training Number of direct care providers Undue Exposure to Radiation Abdomen CT - Use of Contrast Material (CMS) [NEW Thorax CT - Use of Contrast Material (CMS) [NEW Measure Under Development [NEW Number of outpatient abdomen CT studies with and without contrast ('combined studies') Number of outpatient thorax CT studies with and without contrast ('combined studies') 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) 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. Statewide Inpatient/Outpatient Database (SID/SOD) Statewide Inpatient/Outpatient Database (SID/SOD) 9