Appendix A

Appendix A

Table A. Measures Continued, Added, or Removed in FY 2016 IPPS/LTCH

Measure Domain	NQF Endorsement Number	Measure Name	FY 2016 IPPS/LTCH Rule Status
Patient Safety	0139	Central Line-Associated Bloodstream Infection (CLABSI)	Continue in Program
	0138	Catheter-Associated Urinary Tract Infection (CAUTI)	Continue in Program
	0753	Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure	Continue in Program
	1716	Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure	Add to Program
	1717	Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure	Add to Program
	0431	Influenza Vaccination Coverage Among Healthcare Personnel	Add to Program
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	Continue in Program
	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	Continue in Program
	0220	Adjuvant Hormonal Therapy	Continue in Program
Surgical Care Improvement Project (SCIP)	0218	Surgery Patients who Received Appropriate VTE Prophylaxis within 24 Hrs Prior to Surgery to 24 Hrs After Surgery End Time	Remove from Program as of Q4 2015 Discharges
	0284	Surgery Patients on Beta Blocker Therapy Prior to Admission who received a Beta Blocker during the Perioperative Period	Remove from Program as of Q4 2015 Discharges
	0453	Urinary Catheter Removed on Post-Operative Day 1 or Post-Operative Day 2 with Day of Surgery Being Day Zero	Remove from Program as of Q4 2015 Discharges
	0527	Prophylactic Antibiotic Received Within 1 Hr Prior to Surgical Incision	Remove from Program as of Q4 2015 Discharges
	0528	Prophylactic Antibiotic Selection for Surgical Patients	Remove from Program as of Q4 2015 Discharges
	0529	Prophylactic Antibiotic Discontinued Within 24 Hrs After Surgery End Time	Remove from Program as of Q4 2015 Discharges
Oncology Care Measures	0382	Oncology-Radiation Dose Limits to Normal Tissues	Continue in Program
	0383	Oncology: Plan of Care for Pain	Continue in Program
	0384	Oncology: Pain Intensity Quantified	Continue in Program
	0390	Prostate Cancer-Adjuvant Hormonal Therapy for High-Risk Patients	Continue in Program
	0389	Prostate Cancer-Avoidance of Overuse Measure-Bone Scan for Staging Low-Risk Patients	Continue in Program
Patient Engagement/Patient Experience of Care	0166	HCAHPS Patient Experience of Care Survey	Continue in Program
Clinical Effectiveness	1822	External Beam Radiotherapy (EBRT)	Continue in Program

Table B. Summary of PCHQR Information Collection Forms

Forms Associated with the 2016 IPPS/LTCH PPS Final Rule PRA Package		Notes
Program/Procedural Requirements	Measures Exception Paper-Based and Web Application	No changes
	NOP Paper-Based and Web Application
	DACA Paper-Based and Web Application
	Extraordinary Circumstances Exception (ECE) Paper-Based and Web application+
Measure Requirements	All Previously Finalized Measure Data Collection Paper-Based and Web Application	No changes
	NHSN/CDC MRSA and CDI*	Burden estimated by CDC
	NHSN/CDC Influenza Vaccination Coverage Among Healthcare Personnel**	See Statement A for burden estimates

Note: ⁺ Submitted under the Hospital IQR program. We continue to use a standard ECE form.

* Measures covered under OMB Control Number 0920-0666 – approved forms and

documentation available at http://www.cdc.gov/nhsn/acute-care-hospital/cdiff-mrsa/

** Measure covered under OMB Control Number 0920-0666 – approved documentation available at http://www.cdc.gov/flu/toolkit/long-term-care/reporting.htm