Form #4 Form #4 AHRQ QI Data Collection Tool

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

AHRQ QI Data Collection Tool for Improvement Toolkit

Hospital: _________________________

Table 1. Hospital Rates for the AHRQ Inpatient Quality Indicators

Inpatient Quality Indicator Number and Name	Volume (numerator)	Patients at Risk (denominator)	Rate per 100 *
Volume Indicators
1 Esophageal resection		NA	NA
2 Pancreatic resection		NA	NA
4 Abdominal aortic aneurysm repair		NA	NA
5 CABG		NA	NA
6 PTCA		NA	NA
7 Carotid endarterectomy		NA	NA
Post-procedural Mortality Rates
8 Esophageal resection
9 Pancreatic resection
11 AAA repair
12 CABG
30 PTCA
31 Carotid endarterectomy
13 Craniotomy Hip replacement
14 Hip replacement
In-Hospital Mortality Rates
15 AMI
32 AMI, Without Transfer Cases
16 CHF
17 Acute stroke
18 GI hemorrhage
19 Hip fracture
20 Pneumonia
Utilization Rates
21 Cesarean-section delivery
33 Primary Cesarean delivery
22 VBAC (Vaginal Birth After Cesarean), Uncomplicated
34 VBAC, All
23 Laparoscopic Cholecystectomy
24 Incidental appendectomy among elderly
25 Bi-lateral cardiac catheterization

* Calculated as 100*numerator/denominator

Hospital: _________________________

Table 2. AHRQ Patient Safety Indicators

Patient Safety Indicator	Volume (numerator)	Patients at Risk (denominator)	Rate per 1000 *
1 Complications of Anesthesia
2 Death in Low-Mortality DRGs
3 Decubitus Ulcer
4 Failure to Rescue
5 Foreign Body Left During Procedure
6 Iatrogenic Pneumothorax
7 Selected Infections Due to Medical Care
8 Postoperative Hip Fracture
9 Postoperative Hemorrhage or Hematoma
10 Postoperative Physiologic and Metabolic Derangements
11 Postoperative Respiratory Failure
12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis
13 Postoperative Sepsis
14 Postoperative Wound Dehiscence
15 Accidental Puncture or Laceration
16 Transfusion Reaction
17 Birth Trauma – Injury to Neonate
18 Obstetric Trauma – Vaginal with Instrument
19 Obstetric Trauma – Vaginal without Instrument
20 Obstetric Trauma – Cesarean Delivery

* Calculated as 1000*numerator/denominator

Public reporting burden for this collection of information is estimated to average 12 hours per response, including time to program and run the computer programs necessary to produce the measures. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.