Hospital Quality Improvement Program (QIP) 2015-2016 Measurement Specifications Developed by: The Hospital QIP Team Contact: HQIP@partnershiphp.org 2015-2016 Hospital QIP Page 1
Table of Contents 2015-2016 PHC Hospital Quality Improvement Program... 3 Summary of Measures... 3 I. Readmission Domain... 6 1) All-Cause 30-Day Adult Readmission Rate... 6 1a) Follow-up Post Discharge Visits (Back up measure* to Readmission Rate)... 7 II. Advance Care Planning Domain... 8 2) Advance Directive for Patients 65 Years of Age or Older... 8 III. Clinical Quality Domain: OB/Newborn/Pediatrics... 9 3) Elective Delivery before 39 weeks... 9 4) Exclusive Breast Milk Feeding Rate... 10 5) Vaginal Birth after Cesarean (VBAC) Rate, Uncomplicated... 11 6) Timely Participation in California Perinatal Quality Care Collaborative (CPQCC) Data Reporting. 12 7) Timely Participation in California Maternal Quality Care Collaborative (CMQCC) Data Reporting 13 IV. Patient Safety Domain... 13 8) VTE Prophylaxis Rates for Stroke, Surgery, ICU and Non ICU Patients... 13 V. Operations and Efficiency... 15 9) Inpatient Treatment Authorization Requests - Electronic Submission (etars)... 15 10) Health Information Exchange (HIE) Participation... 16 Appendix I: Partnership HealthPlan s Hospital QIP Submission Templates... 18 1. Advance Care Planning... 18 2. Elective Delivery before 39 Weeks... 19 3. Exclusive Breast Milk Feeding Rate... 20 4. VBAC Rate... 21 5. Patient Safety... 22 Appendix II: 2015-2016 HQIP Submission Timeline... 23 2015-2016 Hospital QIP Page 2
2015-2016 PHC Hospital Quality Improvement Program Summary of Measures Measure Target Readmission (20 points) 1. All-Cause 30-day Adult Readmission Rate for all Partnership HealthPlan patients (excludes OB admissions and claims for patients with Medicare coverage) If full or partial points readmission target not met by June 30, 2016: 1a. Percentage of discharges with follow-up visit within 4 calendar days of discharge based on claims and encounter data. 1) All-Cause Readmission Full Points Target: 12.0% Readmission Rate = 20 points Partial Points Target: 12.1% - 15.0% Readmission Rate = 10 points OR Follow Up Post-Discharge Target: 30.0% of members who have a physician office visit within 4 calendar days of discharge = 20 points Advance Care Planning (15 points) 2. Percentage of Patients 65 years of Age and Older with an Advance Directive status recorded as Structured Data (Documentation of Inquiry) OR Percentage of admitted patients 65 years of age and older with Advance Care Planning documentation in the patients medical record (Obtained Advance Care Planning Documentation) Option 1: Documentation of Inquiry Full Points Target: 90.0% = 15 points Partial Points Target: 80.0% - <90.0% = 7.5 points Option 2: Obtained Advance Care Planning Documentation Full Points Target: > 50.0% = 15 points Partial Points Target: 40.0% - <50.0% = 7.5 points Clinical Quality: OB/Newborn/Pediatrics (40 points) 2015-2016 Hospital QIP Page 3
3. Rate of Elective Delivery Before 39 Weeks Full Points Target: 3.0% = 10 points Partial Points Target: 3.1% - 5.0% = 5 points 4. Exclusive Breast Milk Feeding Rate at Time of Discharge from Hospital for all Newborns Full Points Target: Within 3% of the PHC Average (of those hospitals participating in the Hospital QIP) = 10 points Partial Points: Within 5% of the PHC Average (of those hospitals participating in the Hospital QIP) = 5 points 5. VBAC Rate, Uncomplicated Full Points: Pay for Reporting rate from Calendar Year 2015 and first 6 months of 2016 = 10 points No Partial Points available for this measure 6. Timely Participation in CPQCC Data Reporting 7. Timely Participation in CMQCC Data Reporting Full Points Target: Six or more months participating in CPQCC and submitting data to CPQCC for at least 6 months of the measurement year = 5 points Partial Points Target: Join CPQCC and submit data by June 30, 2016 (end of the measurement year) = 2.5 points Full Points Target: Six or more months participating in CMQCC and submitting data to CMQCC for at least 6 months of the measurement year Partial Points Target: Join CMQCC and submit data by June 30, 2016 (end of the measurement year) = 2.5 points Patient Safety (15 points) 8. VTE Prophylaxis: VTE-1 (Non-ICU Patients) VTE-2 (ICU Patients) STK-1 (Stroke Patients) For each VTE measure: Full Points Target: 85.0% = 5 points Partial Points Target: 75.0% - <85.0% = 2.5 points Operations and Efficiency (10 points) 2015-2016 Hospital QIP Page 4
9. Percentage of Inpatient Treatment Authorization Requests submitted electronically (etars) within one business day of an inpatient admission 10. Health Information Exchange (HIE) Participation Measure Full Points Target: 85.0% = 10 points Partial Points Target: 80.0% - < 85.0% = 5 points Meet criteria if: Data contribution (ADT and/or clinical data) to Community HIE by the end of Measurement Year OR Join HIE and submit a clear implementation plan outlining key activities and timelines 2015-2016 Hospital QIP Page 5
I. Readmission Domain 2015-2016 Measure Specifications 1) All-Cause 30-Day Adult Readmission Rate Measure Summary Percentage of acute hospital admissions that are within 30 days of a discharge. Target Patient Population Full Points: 12.0% Readmission Rate = 20 points Partial Points: 12.1% - 15.0% Readmission Rate = 10 points Partnership HealthPlan members admitted to the Hospital for whom Partnership is the primary coverage Measurement Period Fiscal Year 2015 2016 (July 1, 2015 June 30, 2016) Reporting Specifications Bi-annual. Partnership HealthPlan will provide one interim report in April for the period of July December and a final report in October for the full measurement period. Numerator: Total number of readmissions within 30 days. Denominator: Total number of discharges during the measurement year. Exclusions Stays at the following facility types: Long Term Care, Intermediate Care, Sub-acute, rehabilitation, and behavioral health. Excludes acute stays for maternity care and newborn nursery days (OB, Nursery, and NICU stays) as identified by revenue code. PHC members for whom Medicare is the primary coverage. Process for extracting data at PHC Using claims and capitated encounter data, Partnership HealthPlan will identify all acute inpatient stays not subject to the exclusion criteria with a discharge date within the measurement period. The denominator is the count of all continuous stays for members continuously enrolled with Partnership HealthPlan 120 days prior to the index discharge date through 30 days after index discharge date. The numerator is the count of all 30-day readmissions of those in the denominator. For acute-to-acute transfers, the original admission date is the admission date for the entire stay and the transfer s discharge date is the discharge date for the entire stay. 2015-2016 Hospital QIP Page 6
Transfers to rehabilitation, sub-acute, or nursing facilities will be counted as discharges. 1a) Follow-up Post Discharge Visits (Back up measure* to Readmission Rate) *If All-cause Readmission target is not met, points can be earned for this measure Measure Summary Percentage of Partnership HealthPlan patient discharges with a follow-up visit within 4 calendar days of discharge based on claims and encounter data. Target 30.0% of members who have a physician office visit within 4 calendar days of discharge = 20 Points Patient Population Partnership HealthPlan members admitted to the Hospital for whom Partnership is the primary coverage Measurement Period Fiscal year 2015-2016 (July 1, 2015 June 30, 2016) Reporting A final report will be provided to the hospital by October 31 st, 2016, only if the hospital does not meet the full or partial points target for the Readmissions measure. Specifications Numerator: Number of discharges with a qualifying follow-up visit within 4 days of discharge. Denominator: Total number of discharges during the measurement year. Exclusions Stays at the following facility types: Long Term Care, Intermediate Care, Sub-acute, rehabilitation, and behavioral health. Excludes acute stays for maternity care and newborn nursery days (OB, nursery and NICU stays) as identified by revenue code. PHC members for whom Medicare is the primary coverage. Process for extracting data at PHC Using claims and encounter data, Partnership HealthPlan will identify all inpatient discharges from Hospital for all members during the measurement period. A follow-up visit will be counted if there is an office visit billed by a physician indicating a date of service within 4 calendar days of discharge. 2015-2016 Hospital QIP Page 7
II. Advance Care Planning Domain 2) Advance Directive for Patients 65 Years of Age or Older Measure Summary Among all unique patients 65 years old or older admitted to Hospital between July 01, 2015 and June 30, 2016, report on either: Percentage of admitted patients 65 years of age and older with an indication of Advance Directive status recorded as structured data. OR Percentage of admitted patients 65 years of age and older with Advance Care Planning documentation in the patients medical record (i.e. POLST/ Advance Directive). Target Option 1: Documentation of Inquiry Full Points: 90.0% = 15 points Partial Points: 80.0% - 90.0% = 7.5 points Option 2: Obtained Advance Care Planning Documentation Full Points: 50.0% = 15 points Partial Points: 40.0% - <50.0% = 7.5 points Patient Population All-hospital patient population ages 65 years or older Measurement Period Fiscal year 2015 2016 (July 1, 2015 June 30, 2016) Reporting Hospitals report to Partnership HealthPlan by August 31, 2016 Meaningful Use Stage 2 Specifications For detailed specification, follow this link: http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_H ospitalmenu_1_advancedirective.pdf Option 1: Documentation of Inquiry Numerator: The number of patients in the denominator who have an indication of an Advance Directive status entered using structured data. Option 2: Obtained Advance Care Planning Documentation Numerator: The number of patients in the denominator who have Advance Care Planning documentation in the medical record. Option 1&2 2015-2016 Hospital QIP Page 8
Denominator: The number of unique patients age 65 or older admitted during the measurement year. Exclusions Process for submitting data to PHC Any eligible hospital or CAH that admits no patients age 65 years old or older during the EHR reporting period. Hospitals will email EMR report (all formats will be accepted) to Hospital QIP team at: HQIP@partnershiphp.org or fax to (707) 863-4316 III. Clinical Quality Domain: OB/Newborn/Pediatrics 3) Elective Delivery before 39 weeks Measure Summary Target Patient Population Percent of patients with newborn deliveries at 37 to < 39 weeks gestation completed, where the delivery was elective. Full Points: 3.0% = 10 points Partial Points: 3.1% - 5.0% = 5 points All-hospital newborns Measurement Period Calendar year 2015 (January 1, 2015 - December 31, 2015) Reporting Hospitals report to Partnership HealthPlan by August 31, 2016 Joint Commission National Quality Core Measures Specifications (Perinatal Care Measure PC-01) For detailed specifications, follow this link: http://manual.jointcommission.org/releases/tjc2013b/mif0166.ht ml Numerator: The number of patients in the denominator who had elective deliveries. Denominator: Patients delivering newborns with 37 and < 39 weeks of gestation completed during the measurement year. Exclusions Exclusion list retrieved from Core Measure Specifications: ICD-9-CM or ICD-10 Principal Diagnosis Code or ICD-9- CM or ICD-10 Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07 Less than 8 years of age Greater than or equal to 65 years of age Length of stay > 120 days Enrolled in clinical trials Prior uterine surgery Gestational Age < 37 or 39 weeks 2015-2016 Hospital QIP Page 9
Process for submitting data to PHC If the hospital does not have maternity services, this measure does not apply; points are reassigned. Hospitals will email report (all formats will be accepted) to Hospital QIP team at: HQIP@partnershiphp.org or fax to (707) 863-4316 4) Exclusive Breast Milk Feeding Rate Measure Summary Target Patient Population Exclusive breast milk feeding rate for all newborns during the newborn s entire hospitalization. Full Points: Within 3% of the PHC Average (of those hospitals participating in the Hospital QIP) = 10 points Partial Points: Within 5% of the PHC Average (of those hospitals participating in the Hospital QIP) = 5 points Example: If the PHC average rate is 60.0%, full points for 57.0% or above; partial points for 55.0% to 56.9% All-hospital newborns Measurement Period October 1, 2015 March 31, 2016 Reporting Hospitals report to Partnership HealthPlan by August 31, 2016 Joint Commission National Quality Core Measures Specifications (Perinatal Care Measure PC-05) For detailed specifications of the previous 2013 measure, follow this link: http://manual.jointcommission.org/releases/tjc2013b/mif0170.ht ml New detailed specifications for the 2015 revised measure will apply when released by JCAHO. Numerator: The number of newborns in the denominator that were fed breast milk only since birth. Denominator: Single term newborns discharged alive from the hospital during the measurement year. Exclusions Exclusions retrieved from 2015 updated PC-05 specifications: Admitted to the Neonatal Intensive Care Unit (NICU) at this hospital during the hospitalization ICD-10 Other Diagnosis Codes for galactosemia as defined in JCAHO specifications 2015-2016 Hospital QIP Page 10
ICD-10 Principal Procedure Code or ICD-10 Other Procedure Codes for parenteral nutrition as defined in JCAHO Specifications Experienced death Length of Stay >120 days Enrolled in clinical trials Patients transferred to another hospital Patients who are not term or with < 37 weeks gestation completed Process for submitting data to PHC If the hospital does not have maternity services, this measure does not apply; points are reassigned. Hospitals will email report (all formats will be accepted) to Hospital QIP team at: HQIP@partnershiphp.org or fax to (707) 863-4316 5) Vaginal Birth after Cesarean (VBAC) Rate, Uncomplicated Measure Summary Target Percent of Patients who had a previous cesarean delivery who deliver vaginally Full Points Target: Full points for reporting data on the measure for calendar year 2015 and the first six months of 2016 = 10 points. No partial points available for this measure. Patient Population Measurement Period All deliveries at the hospital where the mother had a prior cesarean section Report two separate rates for two different measurement periods: 1) January 1- December 31, 2015 2) January 1- June 30, 2016 Reporting Hospitals report calendar year 2015 data to Partnership HealthPlan by March 1, 2016 and the first 6 months of 2016 by August 31, 2016 2015-2016 Hospital QIP Page 11
Specifications (AHRQ Inpatient Quality Indicator #22) For detailed specifications, follow this link: http://www.qualityindicators.ahrq.gov/downloads/modules/iqi/ V50/TechSpecs/IQI_22_Vaginal_Birth_After_Cesarean_(VBAC) _Rate_Uncomplicate.pdf Numerator: Number of vaginal deliveries among cases meeting inclusion criteria for the denominator Denominator: All deliveries with any listed ICD-9 or IDC-10 diagnosis code for previous Cesarean delivery Exclusions Exclusions retrieved from AHRQ Inpatient Quality Indicators #22 Exclusions include abnormal presentation, preterm, fetal death, multiple gestation, or procedure codes for breech delivery. If the hospital does not have maternity services, this measure does not apply; points are reassigned. Process for submitting data to PHC Hospitals will email report (all formats will be accepted) to Hospital QIP team at: HQIP@partnershiphp.org or fax to (707) 863-4316 6) Timely Participation in California Perinatal Quality Care Collaborative (CPQCC) Data Reporting Measure Summary Participation in the California Perinatal Quality Care Collaborative Target Patient Population Full Points Target: Six or more months participating in CPQCC and submitting data to CPQCC for at least 6 months of the measurement year = 5 points Partial Points Target: Join CPQCC and submit data by June 30, 2016 (end of the measurement year) = 2.5 points All newborns admitted to a nursery in the hospital Measurement Period Fiscal year 2015-2016 (July 1, 2015 June 30, 2016) Reporting CPQCC will send report to Partnership HealthPlan by July 31, 2016, noting hospitals participating and start date for submitting data. PHC will validate the report with the participating hospitals. Specifications All hospitals with maternity services and a Neonatal Intensive Care Unit would report data, per CPQCC parameters. 2015-2016 Hospital QIP Page 12
Exclusions Process for submitting data to PHC If the hospital does not have a Neonatal Intensive Care Unit, this measure does not apply and points are reassigned Report sent by CPQCC 7) Timely Participation in California Maternal Quality Care Collaborative (CMQCC) Data Reporting Measure Summary Target Patient Population Participation in the California Maternal Quality Care Collaborative Full Points Target: Six or more months participating in CMQCC and submitting data to CMQCC for at least 6 months of the measurement year = 5 points Partial Points Target: Join CMQCC and submit data by June 30, 2016 (end of the measurement year) = 2.5 points All newborns admitted to a nursery in the hospital Measurement Period Fiscal year 2015-2016 (July 1, 2015 June 30, 2016) Reporting CMQCC will send report to Partnership HealthPlan by July 31, 2016, noting hospitals participating and start date for submitting data. PHC will validate the report with the participating hospitals. Specifications Exclusions Process for submitting data to PHC All hospitals with maternity services would report data, per CMQCC parameters. If the hospital does not have maternity services, this measure does not apply and points are reassigned Report sent by CMQCC IV. Patient Safety Domain 8) VTE Prophylaxis Rates for Stroke, Surgery, ICU and Non ICU Patients Measure Summary 1) VTE-1- (Non ICU patients) This measure assesses the number of patients who received Venous Thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. 2) VTE-2 (ICU Patients) 2015-2016 Hospital QIP Page 13
This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer). Target Patient Population 3) STK-1 (Stroke Patients) Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. Full Points Target: 85.0% = 15 points (5 points per measure) Partial Points Target: 75.0% - <85.0% = 7.5 points (2.5 points per measure) All-hospital patient population Measurement Period Calendar year 2015 (January 1, 2015 - December 31, 2015) Reporting Hospitals report to Partnership HealthPlan by August 31, 2016 Joint Commission National Hospital Inpatient Quality Measures For detailed specifications, follow this link: http://www.jointcommission.org/specifications_manual_for_nation al_hospital_inpatient_quality_measures.aspx Numerator: 1) VTE-1- (Non ICU patients): Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given: the day of or the day after hospital admission the day of or the day after surgery end date for surgeries that start the day of or the day after hospital admission 2) VTE-2 (ICU Patients): Patients who received VTE prophylaxis, or have documentation why no VTE prophylaxis was given: the day of or the day after ICU admission (or transfer) the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) 3) STK-1 (Stroke Patients): Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission. 2015-2016 Hospital QIP Page 14
Denominator: 1) VTE-1- (Non ICU patients): All- hospital patients admitted in the time period, excluding those admitted to the ICU 2) VTE-2 (ICU Patients): Patients directly admitted or transferred to ICU. 3) STK-1 (Stroke Patients): Ischemic or hemorrhagic stroke patients. Exclusions Process for submitting data to PHC Refer to the following link: http://www.jointcommission.org/specifications_manual_for_nation al_hospital_inpatient_quality_measures.aspx Hospitals will email report (all formats will be accepted) to Hospital QIP team at: HQIP@partnershiphp.org or fax to (707) 863-4316 V. Operations and Efficiency 9) Inpatient Treatment Authorization Requests - Electronic Submission (etars) Measure Summary Target Patient Population Percentage of all Inpatient Treatment Authorization Requests (TARs) submitted electronically within one business day of an inpatient admission. Full Points Target: 85.0% = 10 points Partial Points Target: 80.0% - < 85.0% = 5 points Partnership HealthPlan members admitted to the Hospital for whom Partnership is the primary coverage. Measurement Period Fiscal year 2015-2016 (July 1, 2015 June 30, 2016) Reporting Specifications Partnership HealthPlan will provide monthly reports. Numerator: Total number of Inpatient TARs submitted electronically by Hospital by 11:59 pm of the next business day following admission during the measurement period. Denominator: All Inpatient TARs received from Hospital by Partnership HealthPlan Of California during the measurement period. Exclusions Dual eligible beneficiaries (Medi-Medi patients), members for whom PHC is not primary coverage, members transferred to in- 2015-2016 Hospital QIP Page 15
house swing-bed facilities, I-TARS (newborns without member ID numbers), duplicate TAR submissions (same patient, same admission date), TARS with retroactive timeframes. Process for extracting data at PHC Partnership HealthPlan will extract TAR data submitted by Hospital to PHC and compare the submittal date to the date of admission. 10) Health Information Exchange (HIE) Participation Measure Summary Meet criteria if: Data Contribution (ADT and/or clinical data) to HIE by the end of the measurement year OR Target Join HIE and submit a clear implementation plan outlining key activities and timelines Requirement for participation in Hospital QIP Patient Population N/A Measurement Period Fiscal year 2015-2016 (July 1, 2015 June 30, 2016) Reporting Part I: By October 31, 2015 hospital will indicate which option to achieving HIE participation will be selected. This will be sent to PHC for review and approval, or PHC may return this plan for clarification/modification. A form for submitting this plan will be available by August, 2015, including the specific criteria by which the plan will be evaluated. Part II: By August 31, 2016, Hospital will submit attestation from local community HIE on state of information exchange with hospital or a hospital/health system HIE with the hospital s data. An attestation form will be provided. Specifications Community HIEs from whom attestation will be accepted: Connect Healthcare, Redwood Mednet, Sac Valley Med Share, North Coast Health Information Network, Marin County Health Information Exchange. Meet at least one of the following options for full credit: 1. Attestation of completion of ADT interface including a list of the total number of ADT files received by the community HIE by June 30, 2016 2. Attestation, indicating the number of laboratory results and reports transmitted from the hospital, through a community HIE to at least two different local PCP providers, each using a different non-native Electronic Health Record (not the 2015-2016 Hospital QIP Page 16
Exclusions same EHR as the hospital s system or the hospital s affiliated foundation EHR) 3. Attestation of membership of community HIE in good standing, with a detailed ADT interface implementation plan, including date of implementation before December 31, 2016. No Community Health Information Exchange exists in the community served by the hospital. The Community Health Information Exchange is not able to accept ADT or Clinical data from the Hospital or Hospital HIE. Process for submitting data to PHC Hospitals will email attestation from local community HIE to HQIP@partnershiphp.org or fax to (707) 863-4316 2015-2016 Hospital QIP Page 17
APPENDIX I Appendix I: Partnership HealthPlan s Hospital QIP Submission Templates The following submission forms and the required attachments are due by August 31, 2016, with exceptions noted below. Email all material to HQIP@partnershiphp.org or fax to (707) 863-4316, Attention Hospital QIP Project Coordinator. Should you have any questions, please email us at HQIP@partnershiphp.org 1. Advance Care Planning Complete the following table and attach a hospital report to this submission form. Target population data is reported on All-hospital patients Option Selected (Select One) Option 1: Inquiry Option 2: Documentation Denominator Numerator Percentage (Num/Den) Definitions: Denominator: Total number of unique patients 65 years of age or older admitted between 7/1/2015 6/30/2016. Numerator (Option 1): Patients in the denominator with an indication of an advance directive status entered using structured data. Numerator (Option 2): Patients in the denominator with Advance Care Planning documentation in medical record. 2015-2016 Hospital QIP Page 18
APPENDIX I 2. Elective Delivery before 39 Weeks Complete the following table and attach a hospital report to this submission form. Target population data is reported on Denominator Numerator Percentage (Num/Den) All-hospital deliveries Definitions: Denominator: Patients delivering newborns with 37 and < 39 weeks of gestation completed between 1/1/2015 and 12/31/2015. (Exclusions apply) Numerator: Patients in the denominator with elective deliveries. 2015-2016 Hospital QIP Page 19
APPENDIX I 3. Exclusive Breast Milk Feeding Rate Complete the following table and attach a hospital report to this submission form. Include specifications used to collect data and a brief description of the data collection system in place at your hospital. Target population data is reported on Denominator: Numerator: Percentage: (Num/Den) All-hospital deliveries Definitions: Denominator: Single term newborns discharged alive from the hospital between 10/1/2015 3/31/2016. (Exclusions apply) Numerator: Newborns in the denominator that were fed breast milk only since birth. 2015-2016 Hospital QIP Page 20
APPENDIX I 4. VBAC Rate Complete the following table and attach a hospital report to this submission form. Include specifications used to collect data and a brief description of the data collection system in place at your hospital. Target population data is reported on Denominator: (Deliveries from 37 to 39 weeks) Numerator: Elective deliveries Percentage: (Num/Den) Reporting period 1: (Due March 31, 2015) All-hospital deliveries between January 1, 2015 and December 31, 2015 Reporting period 2: (Due August 31, 2016) All hospital deliveries between January 1, 2016 and June 30, 2016 Definitions: Denominator: All deliveries with any ICD-9 or ICD-10 previous diagnosis of where at least one prior delivery was by cesarean section Numerator: Vaginal deliveries meeting inclusion criteria Note: Any reported rate is eligible for full points. 2015-2016 Hospital QIP Page 21
APPENDIX I 5. Patient Safety Complete the following table and attach a hospital report to this submission form. Measure: Denominator : Numerator: Percentage: (Num/Den) VTE-1 (Non-ICU Patients) VTE-2 (ICU Patients) STK-1 (Stroke Patients) Definitions: Denominator: Unique to each measure- measurement period between 1/1/2015-12/31/2015 Numerator: Unique to each measure- measurement period between 1/1/2015-12/31/2015 2015-2016 Hospital QIP Page 22
APPENDIX II Appendix II: 2015-2016 HQIP Submission Timeline DUE DATE HQIP MEASURE REPORTING TEMPLATE October 31 st, 2015 March 1 st, 2016 August 31 st, 2016 Health Information Exchange Participation VBAC (Report data for Calendar Year 2015) All measures except Readmissions and etar Health Information Exchange Pathway Selection Form available on HQIP Webpage in August, 2015* Template 4 APPENDIX I APPENDIX I, HIE Attestation Form available on HQIP Website by June, 2016* *These forms will also be emailed to HQIP Contacts 2015-2016 Hospital QIP Page 23