Appendix A

PCHQR PRA_Appendix A Aug_4_2014.V2.docx

PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program

Appendix A

OMB: 0938-1175

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Appendix A

Measures Finalized in FY 2015 IPPS/LTCH

Measure Domain

NQF Endorsement Number

Measure Name

Patient Safety

0139

Central Line-Associated Bloodstream Infection (CLABSI)

0138

Catheter-Associated Urinary Tract Infection (CAUTI)

0753

Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure

Cancer Specific Treatment

0223

Adjuvant Chemotherapy is considered or administered within 4 months (120 days) of diagnosis to patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer

0559

Combination Chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c, or Stage II or III hormone receptor negative breast cancer

0220

Adjuvant Hormonal Therapy

Improvement Project (SCIP)Surgical Care

0218

Surgery Patients who Received Appropriate VTE Prophylaxis within 24 Hrs Prior to Surgery to 24 Hrs After Surgery End Time

0284

Surgery Patients on Beta Blocker Therapy Prior to Admission who received a Beta Blocker during the Perioperative Period

0453

Urinary Catheter Removed on Post-Operative Day 1 or Post-Operative Day 2 with Day Surgery Being Day Zero

0527

Prophylactic Antibiotic Received Within 1 Hr Prior to Surgical Incision

0528

Prophylactic Antibiotic Selection for Surgical Patients

0529

Prophylactic Antibiotic Discontinued Within 24 Hrs After Surgery End Time

Oncology Care Measures

0382

Oncology-Radiation Dose Limits to Normal Tissues

0383

Oncology: Plan of Care for Pain

0384

Oncology: Pain Intensity Quantified

0390

Prostate Cancer-Adjuvant Hormonal Therapy for High-Risk Patients

0389

Prostate Cancer-Avoidance of Overuse Measure-Bone Scan for Staging Low-Risk Patients

0166

HCAHPS Patient Experience of Care Survey

Clinical Effectiveness

1822

External Beam Radiotherapy (EBRT)










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