Attachment S List of measures reported by hospitals for the AIM program

AIM MEASURES for Obstetric Hemorrhage Bundle
Outcome Measures (O)	Description	Data Source	Reporting Frequency	Data Coordinator Options	Notes
O1: Severe Maternal Morbidity (SMM)	Denominator: All mothers during their birth admission, excluding ectopics and miscarriages Numerator: Among the denominator, all cases with any SMM code	HDD File (ICD-10)	Quarterly (if available), otherwise annual	●State Agency ●Designated Data Coordinating Body/Hospital System	The SMM Outcome Measures will also be calculated on an annual basis by major race/ethnicity groups: NH white, NH black, Hispanic, NH AI/AN, NH API(NH=Non-Hispanic). Each state will determine which race groups to report, but the first 3 are required.
O2: Severe Maternal Morbidity (excluding cases with only a transfusion code) among All Delivering Women	Denominator: All mothers during their birth admission, excluding ectopics and miscarriages Numerator: Among the denominator, all cases with any non-transfusion SMM code	HDD File (ICD-10)	Quarterly (if available), otherwise annual	●State Agency ●Designated Data Coordinating Body/Hospital System
O3: Severe Maternal Morbidity among Hemorrhage Cases	Denominator: All mothers during their birth admission, excluding ectopics and miscarriages, meeting one of the following criteria: • Presence of an Abruption, Previa or Antepartum hemorrhage diagnosis code • Presence of transfusion procedure code without a sickle cell crisis diagnosis code • Presence of a Postpartum hemorrhage diagnosis code Numerator: Among the denominator, all cases with any SMM code	HDD File (ICD-10)	Quarterly (if available), otherwise annual	●State Agency ●Designated Data Coordinating Body/Hospital System
O4: Severe Maternal Morbidity (excluding cases with only a transfusion code) among Hemorrhage Cases.	Denominator: All mothers during their birth admission, excluding ectopics and miscarriages, meeting one of the following criteria: • Presence of an Abruption, Previa or Antepartum hemorrhage diagnosis code • Presence of transfusion procedure code without a sickle cell crisis diagnosis code • Presence of a Postpartum hemorrhage diagnosis code Numerator: Among the denominator, all cases with any non-transfusion SMM code	HDD File (ICD-10)	Quarterly (if available), otherwise annual	●State Agency ●Designated Data Coordinating Body/Hospital System

Process Measures (P)	Description	Data Source	Reporting Frequency	Data Coordinator Options	Notes
P1: Unit Drills	Report # of drills and the drill topics P1a: In this quarter, how many OB drills (In Situ and/or Sim Lab) were performed on your unit for any maternal safety topic? P1b: In this quarter, what topics were covered in the OB drills?	Hospital	Quarterly	●Perinatal Nurse Manager ●Designated QI Leader	--
P2: Provider Education	Report estimate in 10% increments (round up) P2a: At the end of this quarter, what cumulative proportion of OB physicians and midwives has completed (within the last 2 years) an education program on Obstetric Hemorrhage? P2b: At the end of this quarter, what cumulative proportion of OB physicians and midwives has completed (within the last 2 years) an education program on the Obstetric Hemorrhage bundle elements and the unit-standard protocol?	Hospital	Quarterly	●Perinatal Nurse Manager ●Designated QI Leader	Meant to be informal estimates by nursing leadership similar to the CDC survey to assess breastfeeding practices. Cumulative means "Since the onset of the project, what proportion of the staff have completed the educational program?"
P3: Nursing Education	Report estimate in 10% increments (round up) P3a: At the end of this quarter, what cumulative proportion of OB nurses has completed (within the last 2 years) an education program on Obstetric Hemorrhage? P3b: At the end of this quarter, what cumulative proportion of OB nurses has completed (within the last 2 years) an education program on the Obstetric Hemorrhage bundle elements and the unit-standard protocol?	Hospital	Quarterly	●Perinatal Nurse Manager ●Designated QI Leader
P4: Risk Assessment	Report estimate in 10% increments (round up) At the end of this quarter, what cumulative proportion of mothers had a hemorrhage risk assessment with risk level assigned, performed at least once between admission and birth and shared among the team?	Hospital	Quarterly	●Perinatal Nurse Manager ●Designated QI Leader	Meant to be informal estimates by nursing leadership similar to the CDC survey to assess breastfeeding practices.
P5: Quantified Blood Loss	Report estimate in 10% increments (round up) In this quarter, what proportion of mothers had measurement of blood loss from birth through the recovery period using quantitative and cumulative techniques?	Hospital	Quarterly	●Perinatal Nurse Manager ●Designated QI Leader	Meant to be informal estimates by nursing leadership similar to the CDC survey to assess breastfeeding practices. Formal measurement can include any method beyond visual estimate alone (eg, under-buttock drapes with gradations, weighing clots and sponges, suction canisters with gradations.

Structure Measures (S)	Description	Data Source	Reporting Frequency	Data Coordinator Options	Notes
S1: Patient, Family & Staff Support	Report Completion Date Has your hospital developed OB specific resources and protocols to support patients, family and staff through major OB complications?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader	--
S2: Debriefs	Report Start Date Has your hospital established a system in your hospital to perform regular formal debriefs after cases with major complications?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader	Major complications will be defined by each facility based on volume, with a minimum being The Joint Commission Severe Maternal Morbidity Criteria
S3: Multidisciplinary Case Reviews	Report Start Date Has your hospital established a process to perform multidisciplinary systems-level reviews on all cases of severe maternal morbidity (including women admitted to the ICU, receiving ≥4 units RBC transfusions, or diagnosed with a VTE)?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader
S4: Hemorrhage Cart	Report Completion Date Does your hospital have OB hemorrhage supplies readily available, typically in a cart or mobile box?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader
S5: Unit Policy and Procedure	Report Completion Date Does your hospital have an OB hemorrhage policy and procedure (reviewed and updated in the last 2-3 years) that provides a unit-standard approach using a stage-based management plan with checklists?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader
S6: EHR Integration	Report Completion Date Were some of the recommended OB Hemorrhage bundle processes (i.e. order sets, tracking tools) integrated into your hospital’s Electronic Health Record system?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader	It can be any part of the Obstetric Hemorrhage bundle (i.e. orders, protocols, documentation)

AIM MEASURES for Severe Hypertension/Preeclampsia Bundle
Outcome Measures (O)	Description	Data Source	Reporting Frequency	Data Coordinator Options	Notes
O1: Severe Maternal Morbidity (SMM)	Denominator: All mothers during their birth admission, excluding ectopics and miscarriages Numerator: Among the denominator, all cases with any SMM code	HDD File (ICD-10)	Quarterly (if available), otherwise annual	●State Agency ●Designated Data Coordinating Body/Hospital System	The SMM Outcome Measures will also be calculated on an annual basis by major race/ethnicity groups: NH white, NH black, Hispanic, NH AI/AN, NH API(NH=Non-Hispanic). Each state will determine which race groups to report, but the first 3 are required.
O2: Severe Maternal Morbidity (excluding transfusion codes)	Denominator: All mothers during their birth admission, excluding ectopics and miscarriages Numerator: Among the denominator, all cases with any non-transfusion SMM code	HDD File (ICD-10)	Quarterly (if available), otherwise annual	●State Agency ●Designated Data Coordinating Body/Hospital System
O3: Severe Maternal Morbidity among Preeclampsia Cases	Denominator: All mothers during their birth admission, excluding ectopics and miscarriages, with one of the following diagnosis codes: ●Severe Preeclampsia ●Eclampsia ●Preeclampsia superimposed on pre-existing hypertension Numerator: Among the denominator, cases with any SMM code	HDD File (ICD-10)	Quarterly (if available), otherwise annual	●State Agency ●Designated Data Coordinating Body/Hospital System
O4: Severe Maternal Morbidity (excluding transfusion codes) among Preeclampsia Cases	Denominator: All mothers during their birth admission, excluding ectopics and miscarriages, with one of the following diagnosis codes: ●Severe Preeclampsia ●Eclampsia ●Preeclampsia superimposed on pre-existing hypertension Numerator: Among the denominator, all cases with any non-transfusion SMM code	HDD File (ICD-10)	Quarterly (if available), otherwise annual	●State Agency ●Designated Data Coordinating Body/Hospital System

Process Measures (P)	Description	Data Source	Reporting Frequency	Data Coordinator Options	Notes
P1: Unit Drills	Report # of Drills and the drill topics P1a: In this quarter, how many OB drills (In Situ and/or Sim Lab) were performed on your unit for any maternal safety topic? P1b: In this quarter, what topics were covered in the OB drills?	Hospital	Quarterly	●Perinatal Nurse Manager ●Designated QI Leader	--
P2: Provider Education	Report estimate in 10% increments (round up) P2a: At the end of this quarter, what cumulative proportion of OB physicians and midwives has completed (within the last 2 years) an education program on Severe HTN/Preeclampsia? P2b: At the end of this quarter, what cumulative proportion of OB physicians and midwives has completed (within the last 2 years) an education program on the Severe HTN/Preeclampsia bundle elements and the unit-standard protocol?	Hospital	Quarterly	●Perinatal Nurse Manager ●Designated QI Leader	Meant to be informal estimates by nursing leadership similar to the CDC survey to assess breastfeeding practices. Cumulative means "Since the onset of the project, what proportion of the staff have completed the educational program?"
P3: Nursing Education	Report estimate in 10% increments (round up) P3a: At the end of this quarter, what cumulative proportion of OB nurses has completed (within the last 2 years) an education program on Severe HTN/Preeclampsia? P3b: At the end of this quarter, what cumulative proportion of OB nurses has completed (within the last 2 years) an education program on the Severe HTN/Preeclampsia bundle elements and the unit-standard protocol?	Hospital	Quarterly	●Perinatal Nurse Manager ●Designated QI Leader
P4: Treatment of Severe HTN	Report N/D Denominator: Women with persistent (twice within 15minutes) new-onset Severe HTN (Systolic: ≥ 160 or Diastolic: ≥ 110), excludes women with an exacerbation of chronic HTN Numerator: Among the denominator, cases who were treated within 1 hour with IV Labetalol, IV Hydralazine, or PO Nifedipine	Hospital	Quarterly	●Perinatal Nurse Manager ●Designated QI Leader	The hardest part of this measure is to identify cases with persistent Severe Hypertension. Recommended use at least 2 systems (i.e. logbooks, EHR, pharmacy records) for identification of denominator cases.

Structure Measures (S)	Description	Data Source	Reporting Frequency	Data Coordinator Options	Notes
S1: Patient, Family & Staff Support	Report Completion Date Has your hospital developed OB specific resources and protocols to support patients, family and staff through major OB complications?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader	--
S2: Debriefs	Report Start Date Has your hospital established a system in your hospital to perform regular formal debriefs after cases with major complications?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader	Major complications will be defined by each facility based on volume, with a minimum being The Joint Commission Severe Maternal Morbidity Criteria
S3: Multidisciplinary Case Reviews	Report Start Date Has your hospital established a process to perform multidisciplinary systems-level reviews on all cases of severe maternal morbidity (including women admitted to the ICU, receiving ≥4 units RBC transfusions, or diagnosed with a VTE)?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader
S4: Unit Policy and Procedure	Report Completion Date Does your hospital have a Severe HTN/Preeclampsia policy and procedure (reviewed and updated in the last 2-3 years) that provides a unit-standard approach to measuring blood pressure, treatment of Severe HTN/Preeclampsia, administration of Magnesium Sulfate, and treatment of Magnesium Sulfate overdose?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader	--
S5: EHR Integration	Report Completion Date Were some of the recommended Severe HTN/Preeclampsia bundle processes (i.e. order sets, tracking tools) integrated into your hospital’s Electronic Health Record system?	Hospital	Once	●Perinatal Nurse Manager ●Designated QI Leader	It can be any part of the Severe Hypertension bundle (i.e. orders, protocols, documentation)

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