Compass Hospital Improvement Innovation Network (HIIN) Measure Set

Compass Hospital Improvement Innovation Network (HIIN) Measure Set * Statewide s National Safety Healthcare Network () * Self- f Focus Area Adverse Drug Event Rate Adverse Drug Events riginating During Hospital Stay, (AHRQ Statistical Brief #109) Blood Glucose Less Than 50 rocess ()/ utcome () Number of Acute Care, SNF, Swing Bed and bservation adverse drug events Number of Acute Care adverse drug events that cause harm Number of blood glucose measurements (per lab reports, CT, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Facility, Swing Bed and bservation patients where blood glucose <50 Number of Acute Care, SNF, Swing Bed and bservation patient days and Swing Bed discharges Number of blood glucose measurements (per lab reports/ct, EMR, Charge Data, etc.) for Acute Care, Skilled Nursing Care, Swing Bed and bservation patients Statewide s (if available), therwise Self- g # 21 * 23 * 24 * INRs Greater Than 5 Number of lab measurements for Acute Care, Skilled Nursing Facility, Swing Bed and bservation patients on Warfarin where documented INR >5 Number of INR lab measurements for Acute Care, Skilled Nursing Facility, Swing Bed and bservation patients on Warfarin 25 * (NEW) (NEW) CLSTRIDIUM DIFF (NEW) CLSTRIDIUM DIFF (NEW) CLSTRIDIUM DIFF (NEW) Stat naloxone Administration pioid Therapy Treatment lan revalence of naloxone usage in community setting prior to admission Healthcare facility-onset Clostridium difficile Infection Rate Clostridium difficile revalence Hand Hygiene Compliance Number of episodes when a reversal agent (e.g. naloxone) is administered to Acute Care, Skilled Nursing Facility, Swing Bed and bservation patients prescribed opioids Number of patients discharged from a hospital on opioids with patient-specific goals of therapy at discharge Number of patients who received naloxone in community setting prior to admission (include ambulance, in-home, and law enforcement use of naloxone) Number of healthcare facility-onset Clostridium difficile infections, Swing Bed and bservation patients prescribed opioids Number of patients discharged on opioids Number of Acute Care admissions Number of Acute Care inpatient days Number of Clostridium difficile Lab ID events Number of Acute Care inpatient admissions Number of observations where appropriate handwashing technique was applied Number of handwashing observations 26 * 27 * 28 * 30 32 33 * *Focus area optional depending on hospital services age 1

f Focus Area CLSTRIDIUM DIFF (NEW) Contact recaution Compliance SIR - ICU Units excluding NICU, (NQF 0138) rocess ()/ utcome () SIR - ICU Units + ther Units, (NQF 0138) Catheter-Associated Urinary Tract Infection Rate Unnecessary Urinary Catheters Number of contact precautions performed consistent with guidelines bserved number of infections for ICU units excluding NICU based on aggregate bserved number of infections for ICU units plus other units based on aggregate Number of observations Expected number of infections for ICU units excluding NICU based on aggregate Expected number of infections for ICU units plus other units based on aggregate Number of hospital-acquired urinary tract infections Number of Acute Care urinary catheter days Swing Bed inpatients with new indwelling urinary catheters inserted without appropriate indication and Swing Bed inpatients with new indwelling urinary catheter insertions g # 34 * 36 37 * CLABSI Emergency Department Catheter Utilization Urinary Catheter Utilization Ratio * CLABSI SIR - ICU Units including NICU, (NQF 0139) * CLABSI SIR - ICU Units + ther Units, (NQF 0139) *Central Line-Associated Bloodstream Infection Rate Number of Emergency Department urinary catheter placements in the Emergency Department Swing Bed inpatient days with urinary catheter in place bserved number of CLABSI infections for ICU units excluding NICU based on aggregate Number of Emergency Department visits and Swing Bed inpatient days Expected number of CLABSI infections for ICU units excluding NICU based on aggregate Statewide s (if available), therwise Self- 40 * 39 CLABSI bserved number of CLABSI infections for ICU Expected number of CLABSI infections for ICU units plus other units based on aggregate units plus other units based on aggregate CLABSI Number of hospital-acquired, central line-associated Number of Acute Care central line catheter days bloodstream infections 41 CLABSI *Cental Line Utilization Ratio Number of central line days Total number of patient days 42 CLABSI *Central Line Insertion Compliance ans Swing Bed inpatients with full ICC line and/or central line catheter insertion bundle compliance and Swing Bed inpatients with ICC line and/or central line insertions 43 * Fall Resulting in Fracture or Dislocation (CMS HAC) Falls Resulting in No Apparent Injury Rate Number of Acute Care inpatient discharges with ICD-9/10 fracture or dislocation code(s) not present on admission Number of falls for Acute Care, Skilled Nursing Facility, Swing Bed and bservation 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 Number of Acute Care discharges Nursing Care, Swing Bed and bservation patient Statewide s (if available), therwise Self- 45 * 47 * *Focus area optional depending on hospital services age 2

f Focus Area rocess ()/ utcome () g # Fall Resulting in Minor Injury Rate Number of for Acute Care, Skilled Nursing Facility, Swing Bed and bservation patients that have unplanned descent to the floor resulting in minor cuts, minor bleeding, minor skin abrasions, minor swelling and minor contusions or bruising Nursing Care, Swing Bed and bservation patient 47 * Fall Resulting in Moderate Injury Rate Number of for Acute Care, Skilled Nursing Facility, Swing Bed and bservation patients that have unplanned descent to the floor resulting in excessive bleeding, lacerations requiring sutures, temporary loss of consciousness or moderate head trauma Nursing Care, Swing Bed and bservation patient 48 * Fall Resulting in Major Injury Rate Number of for Acute Care, Skilled Nursing Facility, Swing Bed and bservation patients 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 R Nursing Care, Swing Bed and bservation patient 49 * Fall Resulting in Death Rate Number of for Acute Care, Skilled Nursing Facility, Swing Bed and bservation patients that have unplanned descent to the floor resulting in death Nursing Care, Swing Bed and bservation patient 50 * Fall Risk Assessment on Admission, Number of Acute Care, Skilled Nursing Care, Swing Bed and bservation patients assessed for fall Swing Bed and bservation patients admitted risk on admission 51 * Count of Assisted Falls, No denominator for this measure Swing Bed and bservation events where the patient is assisted or eased to the floor 51 * RESSURE ULCER ressure Ulcer Rate, Stage 3+ (AHRQ) Number of 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-a Number of discharges for Acute Care, Skilled Nursing and Swing Bed patients Statewide s (if available), therwise Self- 53 * RESSURE ULCER At-risk atients Receiving Full ressure Ulcer reventative 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 Care and Swing Bed inpatients 55 * READMINS Unplanned All-Cause, 30-Day Readmissions to Any Hospital Number of Acute Care inpatient discharges that Number of Acute Care inpatient discharges meet criteria inclusion as a readmission to any meeting eligibility for inclusion as an index hospital using unplanned, 30-day, all-cause, all-payer admission methodology Statewide s (if available), therwise Self- 57 * READMINS Unplanned All-Cause, 30-Day Readmissions to Same Hospital Number of Acute Care inpatient discharges that Number of Acute Care inpatient discharges meet criteria inclusion as a readmission to the same meeting eligibility for inclusion as an index hospital using unplanned, 30-day, all-cause, all-payer admission methodology Statewide s (if available), therwise Self- 58 * *Focus area optional depending on hospital services age 3

f Focus Area rocess ()/ utcome () g # READMINS Handover Communication Swing Bed inpatient discharges where critical information is transmitted to the next site of care (e.g. office, LTC, HH) or person continuing care Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges 63 * READMINS Community rovider Involvement in identifying ost- Discharge Needs Swing Bed inpatient discharges where community providers (e.g. home care, primary care, nurses, skilled nursing) were included in assessing post discharge needs Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges 61 * READMINS READMINS SEVERE SESIS AND SETIC SHCK (NEW) ost-hospital Follow-up Appointment atient Teach-Back ostoperative Sepsis Rate, (AHRQ SI 13) Swing Bed inpatient discharges with follow-up appointment scheduled before discharge in accordance with risk assessment Number of observations of nurses where teach-back is used to assess understanding Number of Acute Care elective surgical inpatient discharges with any secondary ICD-9/10 diagnosis code for sepsis Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed inpatient discharges Number of observations of nurse teaching Number of Acute Care elective surgical inpatient discharges with any-listed ICD-9/10 procedure code for an operating room procedure and admission type recorded as elective 62 * 60 * Statewide s (if available), therwise Self- 65 * SEVERE SESIS AND SETIC SHCK (NEW) Severe Sepsis and Septic Shock 3 hour Management Bundle Compliance (NQF 0500) Swing Bed inpatients in the denominator population who receive all elements of the 3 hour Severe Sepsis and Septic Shock Management Bundle and Swing Bed inpatients presenting with severe sepsis or septic shock (exclude patients comfort care only, where central line cannot be placed or is contraindicated, or where clinical condition precludes total measure completion) 66 * SEVERE SESIS AND SETIC SHCK (NEW) Severe Sepsis and Septic Shock 6-hour Management Bundle Compliance (NQF 0500) Number of Acute Care, Skilled Nursing and Swing Bed inatients in the denominator population who receive all elements of the 6 hour Severe Sepsis and Septic Shock Management Bundle and Swing Bed inpatients presenting with severe sepsis or septic shock (exclude patients comfort care only, where central line cannot be placed or is contraindicated, or where clinical condition precludes total measure completion) 68 * *CDC Harmonized rocedure- Specific SIR - Colon Surgeries, (CMS IQR xx), (NQF 0753) bserved number of Colon infections based on aggregate Expected number of Colon infections based on aggregate *CDC Harmonized rocedure- Specific SIR - Abdominal Hysterectomies, (NQF 0753) bserved number of Abdominal Hysterectomy infections based on aggregate Expected number of Abdominal Hysterectomy infections based on aggregate *Focus area optional depending on hospital services age 4

f Focus Area rocess ()/ utcome () g # *CDC Harmonized rocedure- Specific SIR - Total Hip Replacements, (NQF 0753) *CDC Harmonized rocedure- Specific SIR - Total Knee Replacements, (NQF 0753) bserved number of Total Hip infections based on aggregate bserved number of Total Knee infections based on aggregate Expected number of Total Hip infections based on aggregate Expected number of Total Knee infections based on aggregate *Colon Surgical Site Infection Rate Number of hospital-acquired colon surgical site infections Number colon surgical episodes 70 *Abdominal Hysterectomy Surgical Site Infection Rate *Hip Replacement Surgical Site Infection Rate *Knee Replacement Surgical Site Infection Rate *Surgery atients with erioperative Temperature Management Number of hospital-acquired abdominal hysterectomy surgical site infections Number of hospital-acquired hip replacement surgical site infections Number of hospital-acquired knee replacement surgical site 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 abdominal hysterectomy surgical episodes Number of hip replacement surgical episodes Number of knee replacement surgical episodes Number of surgical inpatients undergoing procedure under general or neuraxial anesthesia of greater than or equal to 60 minutes duration 71 72 74 75 * (NEW) VAE VAE VAE VAE *Surgical Safety Checklist Compliance *Ventilator-Associated Condition (VAC) *Infection-Related Ventilator- Associated Complication (IVAC) *ossible/robable Ventilator- Associated neumonia *Ventilator Bundle Compliance Number of operating room procedures in which the checklist was used Number of operating room procedures during observed time period Number of events that meet VAC criteria Number of ventilator days Number of events that meet IVAC criteria Number of ventilator days Number of events that meet possible/probable Ventilator-Associated neumonia criteria Number of ventilator days Number of ICU patients in the denominator Number of ICU patients on mechanical ventilation population on mechanical ventilation with full on day of week sample ventilator-associated prevention bundle compliance 76 * 78 79 80 81 * VTE ost-perative ulmonary Embolism (E) or Deep Venous Thrombosis (DVT) (AHRQ) Number of Acute Care surgical inpatients with non- A secondary ICD-9/10 code(s) for DVT or E Number of Acute Care surgical inpatient discharges excluding cases where DVT/E are present on admission Statewide s (if available), therwise Self- 83 * VTE (NEW) Venous Thromboembolism Warfarin Therapy Discharge Instructions (CMS VTE-5) Number of patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin Number of patients with confirmed VTE discharged on warfarin therapy 86 * *Focus area optional depending on hospital services age 5

f Focus Area VTE VTE Appropriate rophylaxis rocess ()/ utcome (), Swing Bed and bservation patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given Number of admissions to Acute Care, Skilled Nursing Facility, Swing Bed and bservation patients with stays of >48 hours g # 84 * *Focus area optional depending on hospital services age 6

Compass Hospital Improvement Innovation Network (HIIN) Additional Harm Area Measure Set (TINAL) * Statewide s National Safety Healthcare Network () * Self- f Focus Area MDR/ANTI- MICRBIAL STEWARDSHI (NEW) MDR/ANTI- MICRBIAL STEWARDSHI (NEW) Carbapenem-resistant Enterobacteriaceae (CRE) revalence Standardized Antimicrobial Administration Ratio (SAAR) rocess ()/ utcome () Number of LabID CRE events Number of Acute Care Inpatient days Number of observed days of antimicrobial therapy Number of days of antimicrobial therapy predicted reported by a healthcare facility for a specified category for a healthcare facility's use of a specified of antimicrobial agents used in a patient care location or category of antimicrobial agents in a patient care group of locations location or group of locations, calculated by applying negative binomial regression modeling to nationally aggregated AU g # 88 89 MDR/ANTI- MICRBIAL STEWARDSHI (NEW) MDR/ANTI- MICRBIAL STEWARDSHI (NEW) HSITAL CULTURE F SAFETY/WRKER SAFETY HSITAL CULTURE F SAFETY/WRKER SAFETY HSITAL CULTURE F SAFETY/WRKER SAFETY UNDUE EXSURE T RADIATIN Antibiotic Time ut Antimicrobial agent days Work-related Back Injuries Needlesticks Safe atient Handling rogram Equipment Checklist Compliance Abdomen CT - Use of Contrast Material (CMS) Number of patients administered antibiotics that have antibiotic "time out" in order to reassess the continuing need and choice of antibiotics, within 48 hours of initiation of antimicrobial therapy Number of patient-days when any antimicrobial was prescribed/administered (alone or in combination) Number of patients prescribed/administered antimicrobial therapy Total number of patient days 90 * 90 * Number of work-related back injuries Number of FTEs 92 * Number of needlestick events Number of FTEs 93 * Number of units with all checklist items 'In lace' Number of units assessed 94 * Number of abdomen CT studies with and without contrast ('combined studies') Number of abdomen CT studies performed (with Statewide s (if contrast, without contrast or both with and without available), therwise Selfcontrast) 96 * *Focus area optional depending on hospital services age 7

f Focus Area rocess ()/ utcome () g # UNDUE EXSURE T RADIATIN Thorax CT - Use of Contrast Material (CMS) Number of thorax CT studies with and without contrast ('combined studies') Number of thorax CT studies performed (with Statewide s (if contrast, without contrast or both with and without available), therwise Selfcontrast) 97 * UNDUE EXSURE T RADIATIN Total CT Dose Capture Compliance - Dose Length roduct (DL) Total number of CTs in which the total DL is recorded Total number of CTs 98 * UNDUE EXSURE T RADIATIN Total CT Dose Capture Compliance - Volume CT Dose Index (CTDIvol) Total number of CTs in which the total CTDIvol is recorded Total number of CTs 98 * UNDUE EXSURE T RADIATIN Total CT Dose Capture Compliance - Size-specific Dose Estimate (SSDE) Total number of CTs in which the total SSDE is recorded Total number of CTs 99 * MBQI HASE 3 - MBQI HASE 3 - facility where all elements were communicated to the receiving facility all Administatrive Communication (nurse-to-nurse communication and physician-to-physician communication) was communicated 106 * 107 * MBQI HASE 3 - all atient Information (name, address, age, gender, significant other contact info and insurance information) was communicated 107 * MBQI HASE 3 - all Vital Signs (pulse, respiratory rate, blood pressure, oxygen saturation, temperature and Glasgow Coma Scale/neuro assessment) was communicated 107 * MBQI HASE 3 - all Medication Information (medications administered in ED, allergies and home medications) was communicated 107 * MBQI HASE 3 - all actitioner-generated Information (history and physical, reason for transfer and plan of care) was communicated 107 * *Focus area optional depending on hospital services age 8

f Focus Area rocess ()/ utcome () g # MBQI HASE 3 - all the Nurse-Generated Information (nursing assessments/interventions/response, sensory status, catheters, immobilizations, respiratory support and oral limitations) was communicated 108 * MBQI HASE 3 - all Tests and rocedures done and Test and rocedure Results Sent were communicated 108 * BSTETRICAL BSTETRICAL *Early Elective Delivery *rimary Cesarean Delivery Rate, Uncomplicated Number of elective maternal deliveries between 37-39 weeks gestation with no medical indication Number of maternal inpatients with either MS-DRG code for Cesarean delivery or any-listed ICD-9/10 procedure code(s) for Cesarean delivery without anylisted ICD-9/10 procedure code(s) for hysterotomy All deliveries between 37-39 weeks gestation Number of deliveries 100 * Statewide s (if available), therwise Self- 101 * BSTETRICAL BSTETRICAL BSTETRICAL *Birth Trauma Rate - Injury to Newborn (ARHQ SI 18) *bstetrical Trauma Rate - Vaginal Delivery With Instrument *bstetrical Trauma Rate - Vaginal Delivery Without Instrument (ARHQ SI 19) Number of Newborns with ICD-9/10 code(s) for birth trauma Number of vaginally-delivering, instrument-assisted Moms with ICD-9/10 code(s) for 3rd or 4th degree obstetric trauma Number of vaginally-delivering, non instrument-assisted Moms with ICD-9/10 code(s) for 3rd or 4th degree obstetric trauma Number of Newborns Number of vaginal deliveries with ICD-9/10 procedure code(s) for instrument-assisted delivery Number of vaginal deliveries without ICD-9/10 procedure code(s) for non instrument-assisted delivery Statewide s (if available), therwise Self- Statewide s (if available), therwise Self- Statewide s (if available), therwise Self- 102 * 103 * 104 * *Focus area optional depending on hospital services age 9