List of Measures Included in the CMS Impact Assessment
IQR measures
Measures Requiring Abstraction and Submission by the Hospital or Its Vendor
Acute Myocardial Infarction (AMI)
AMI-1 Aspirin at Arrival
AMI-3 ACEI or ARB for LVSD
AMI-5 Beta-Blocker Prescribed at Discharge
AMI-7 Median Time to Fibrinolysis
AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8 Median Time to Primary PCI
AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention
Heart Failure (HF)
HF-2 Evaluation of LVS Function
Stroke (STK)
STK-1 Venous Thromboembolism (VTE) Prophylaxis
STK-2 Discharged on Antithrombotic Therapy
STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK-4 Thrombolytic Therapy
STK-5 Antithrombotic Therapy By End of Hospital Day 2
STK-6 Discharged on Statin Medication
STK-8 Stroke Education
STK-10 Assessed for Rehabilitation
Venous Thromboembolism (VTE)
VTE-1 Venous Thromboembolism Prophylaxis
VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis
VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
VTE-4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram
VTE-5 Venous Thromboembolism Warfarin Therapy Discharge Instructions
VTE-6 Hospital Acquired Potentially-Preventable Venous Thromboembolism
Pneumonia (PN)
PN-3a Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival
PN-6 Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patient
PN-6a Initial Antibiotic Selection for CAP in Immunocompetent – ICU Patient
PN-6b Initial Antibiotic Selection for CAP in Immunocompetent – Non–ICU Patient
Children’s Asthma Care (CAC)
CAC-1 Relievers for Inpatient Asthma
CAC-2 Systemic Corticosteroids for Inpatient Asthma
CAC-3 Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
Surgical Care Improvement Project (SCIP)
SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4 Cardiac Surgery Patients With Controlled Postoperative Blood Glucose
SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal
SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero (8,13)
SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who received a Beta-Blocker During the Perioperative Period (6,12)
SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to
Surgery to 24 Hours After Surgery (3,12)
Emergency Department (ED)
ED-1a Median Time from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate
ED-1b Median Time from ED Arrival to ED Departure for Admitted ED Patients – Reporting Measure
ED-1c Median Time from ED Arrival to ED Departure for Admitted ED Patients – Observation Patients
ED-1d Median Time from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients
ED-2a Admit Decision Time to ED Departure Time for Admitted Patients – Overall Rate
ED-2b Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure (9,10)
ED-2c Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients
Immunization (IMM)
IMM-1a Pneumococcal Immunization – Overall Rate
IMM-1b Pneumococcal Immunization – Age 65 and older
IMM-1c Pneumococcal Immunization – High Risk Populations (Age 5 through 64 years)
IMM-2 Influenza Immunization
Healthcare Associated Infection Measure (HAI)
Central-Line Associated Bloodstream Infection (CLABSI)
Surgical Site Infection (SSI-colon, SSI-abdominal hysterectomy)
Catheter-Associated Urinary Tract Infection (CAUTI)
MRSA Bacteremia (10)Clostridium Difficile (C.difficile)
Healthcare Personnel Influenza Vaccination
Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)
Hospital Consumer Assessment of Healthcare Providers and Systems Survey
Tobacco Treatment (TOB)
TOB-1 Tobacco Use Screening
TOB-2 Tobacco Use Treatment Provided or Offered
TOB-2a Tobacco Use Treatment
TOB-3 Tobacco Use Treatment Provided or Offered at Discharge
TOB-3a Tobacco Use Treatment at Discharge
TOB-4 Tobacco Use: Assessing Status After Discharge
Substance Use
(SUB)SUB-1 Alcohol Use Screening
SUB-2 Alcohol Use Brief Intervention Provided or Offered
SUB-2a Alcohol Use Brief Intervention
SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge
SUB-3a Alcohol and Other Drug Use Disorder Treatment at Discharge
SUB-4 Alcohol and Drug Use: Assessing Status after Discharge
Measures Requiring Web-Based Hospital Data Entry
Structural Measures
Participation in a Systematic Database for Cardiac Surgery
Participation in a Systematic Clinical Database Registry for Stroke Care
Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care
Participation in a Systematic Clinical Database Registry for General Surgery
Data Accuracy and Completeness Acknowledgement
Data Accuracy and Completeness Acknowledgement
Perinatal Care
PC-01 Elective Delivery Prior to 39 Completed Weeks Gestation: Percentage of Babies Electively Delivered Prior to 39 Completed Weeks Gestation
Measure Information Obtained from Claims-Based Data
Mortality Measures (Medicare patients)
MORT-30-AMI Acute Myocardial Infarction (AMI) 30-Day Mortality Rate
MORT-30-HF Heart Failure (HF) 30-Day Mortality Rate
MORT-30-PN Pneumonia (PN) 30-Day Mortality Rate
MORT-30-COPD Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality Rate
MORT-30-STK Acute Ischemic Stroke (STK) 30-Day Mortality Rate
Readmission Measures (Medicare patients)
READM-30-AMI Acute Myocardial Infarction (AMI) 30-Day Readmission Rate
READM-30-HF Heart Failure (HF) 30-Day Readmission Rate
READM-30-PN Pneumonia (PN) 30-Day Readmission Rate
Hip/Knee Readmission Hospital-Level 30-Day All-Cause Risk- Standardized Readmission Rate (RSRR) Following Elective Total Hip Arthroplasty (THA)/Total Knee Arthroplasty (TKA)
HWR Hospital-Wide All-Cause Unplanned Readmission (HWR)
READM-30-COPD Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission Rate
READM-30-STK Stroke (STK) 30-Day Readmission Rate
Agency for Healthcare Research and Quality (AHRQ) Measures
PSI 90 Complication/Patient Safety for Selected Indicators
PSI 4 Death Among Surgical Patients with Serious Treatable Complications (Harmonized with Nursing Sensitive Care Measure, Failure to Rescue)
Surgical Complications
Hip/Knee Complications Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA)
Cost Efficiency Measures
Medicare Spending per Beneficiary (MSPB)
Acute Myocardial Infarction (AMI) Payment per Episode of Care
Measures for Electronic Reporting via Certified Electronic Health Record Technology (CEHRT) (voluntary participation CY 2014)
STK-2 Discharged on Antithrombotic Therapy
STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK-4 Thrombolytic Therapy
STK-5 Antithrombotic Therapy By End of Hospital Day 2
STK-6 Discharged on Statin Medication
TK-8 Stroke Education
STK-10 Assessed for Rehabilitation
VTE-1 Venous Thromboembolism Prophylaxis
VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis
VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
VTE-4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or NomogramV
TE-5 Venous Thromboembolism Warfarin Therapy Discharge Instructions
VTE-6 Hospital Acquired Potentially-Preventable Venous Thromboembolism (10,14)
ED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients
ED-2 Admit Decision Time to ED Departure Time for Admitted Patients
PC-01 Elective Delivery Prior to 39 Completed Weeks Gestation: Percentage of Babies Electively Delivered Prior to 39 Completed Weeks Gestation
OQR measures
Cardiac Care (AMI and CP) Measures
OP-1: Median Time to Fibrinolysis
OP-2: Fibrinolytic Therapy Received Within 30 Minutes
OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention
OP-4: Aspirin at Arrival
OP-5: Median Time to ECG
Surgery
OP-6 Timing of Antibiotic Prophylaxis
OP-7 Antibiotic Selection
Imaging Efficiency Measures
OP-8: MRI Lumbar Spine for Low Back Pain
OP-9: Mammography Follow-up Rates
OP-10: Abdomen CT – Use of Contrast Material
OP-11: Thorax CT – Use of Contrast Material
OP-13: Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery
OP-14: Simultaneous Use of Brain Computed Tomography (CT) and Sinus CT
ED-Throughput
OP-18 Median Time from ED Arrival to ED Departure for Discharged ED Patients
OP-20 Door to Diagnostic Evaluation by a Qualified Medical Professional
OP-22 Left Without Being Seen
Pain Management
OP-21 Median Time to Pain Management for Long Bone Fracture
Stroke
OP-23 Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival
Structural and Web-Based Measures
OP-12: The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their ONC-Certified EHR System as Discrete Searchable Data
OP-17: Tracking Clinical Results between Visits
OP-25: Safe Surgery Checklist Use
OP-26: Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures
OP-27: Influenza Vaccination Coverage among Healthcare Personnel
OP-29 Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk
OP-30 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
OP-31 Cataracts – Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ann Clancy |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |