Hospital Quality Measures Matrix

CMS-QIO

* APU

** HQA

JCAHO

IHI

GWTG

Acute Myocardial Infarction (AMI)

Aspirin at Arrival

x

x

x

x

x

x

Aspirin Prescribed at Discharge

x

x

x

x

x

x

ACEI or ARB for LVSD at Discharge

x

x

x

x

x

x

Adult Smoking Cessation Advice/Counseling

x

x (1)

x

x

x

Beta Blocker Prescribed at Discharge

x

x

x

x

x

x

Beta Blocker at Arrival

x

x

x

x

x

x

Mean Time to Thrombolysis

x

x

Thrombolytic Agent Received Within 30 Minutes of Hospital Arrival

x

x (1)

x

x

x

Mean Time to PCI

x

x

PCI Received Within 120 Minutes of Hospital Arrival

x

x (2)

x

x

x

Heart Failure (HF)

CMS-QIO

* APU

** HQA

JCAHO

IHI

GWTG

Discharge Instructions

x

x (1)

x

LVF Assessment

x

x

x

x

ACEI or ARB for LVSD at Discharge

x

x

x

x

Adult Smoking Cessation Advice/Counseling

x

x(1)

x

Pneumonia (PN)

CMS-QIO

* APU

** HQA

JCAHO

IHI

GWTG

Oxygenation Assessment

x

x

x

x

Pneumococcal Vaccination

x

x

x

x

Blood Culture Within 24 hours Prior to or After Hospital Arrival

x

x

Blood Culture Before First Antibiotic

x

x (1)

x

Adult Smoking Cessation Advice/Counseling

x

x (1)

x

Antibiotic Timing (Mean)

x

Initial Antibiotic Received Within 8 Hours of Hospital Arrival

x

Initial Antibiotic Received Within 4 Hours of Hospital Arrival

x

x

x

x

Initial Antibiotic Selection for CAP in Immunocompetent Patient

x

x (2)

Initial Antibiotic Selection for CAP in Immunocompetent – ICU Patient

x

Initial Antibiotic Selection for CAP in Immunocompetent – Non -- ICU Patient

x

Influenza Vaccination

x

x (2)

x

Surgical Infection Prevention (SIP)

CMS-QIO

* APU

** HQA

JCAHO

IHI

GWTG

Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision

x

x (2)

x (3)

x

Prophylactic Antibiotic Selection for Surgical Patients

x

x (2)

x (3)

x

Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time

x

x (2)

x (3)

x

Cardiac Surgery Patients with Controlled Perioperative Serum Glucose (<=200mg/dL)

x

x

Appropriate surgical site hair removal

x

x

Colorectal surgical patients who maintained normothermia (36º- 39º C or 96.8º- 100.4º F) during the perioperative period.

x

Major surgical patients with controlled perioperative serum glucose (= 200mg/dl)

x (TEST MEASURE)

x

Major surgical patients without planned hypothermia who maintained normothermia (36º- 39ºC or 96.8º- 100.4ºF) during the perioperative period

x (TEST MEASURE)

Cardiovascular Complications

CMS-QIO

* APU

** HQA

JCAHO

IHI

GWTG

Major non-cardiac surgery patients with prior evidence of coronary artery disease, without contraindications to receiving beta-blockers, who received beta-blockers during the perioperative period.

x

Major surgery patients, maintained on a beta-blocker prior to surgery that received a beta-blocker during the perioperative period

x

Venous Thromboembolism

CMS-QIO

* APU

** HQA

JCAHO

IHI

GWTG

Major surgical patients who received any perioperative prophylaxis for venous thromboembolism (VTE)

x

x

Major surgical patients who received recommended prophylaxis based on the surgical level of risk for VTE

x

x (4)

Major surgical patients who received appropriate prophylaxis based on the surgical level of risk for venous thromboembolism

x

x (4)

Respiratory Complications

CMS-QIO

* APU

** HQA

JCAHO

IHI

GWTG

Major surgical patients on a ventilator, in any intensive care or step-down unit, whose post-operative orders included elevating the head of the bed (HOB) greater than or equal to 30 degrees and documentation of elevation of the HOB greater than or equal to 30 degrees

x

x (4)

x

Major surgical patients on a ventilator, in any intensive care or step-down unit, without contraindications to PUD prophylaxis, who received PUD prophylaxis

x (TEST MEASURE)

x (4)

x

Major surgical patients on a ventilator, in any intensive care or step-down unit, who are placed on a ventilator-weaning protocol

x (TEST MEASURE)

x

Major surgical patients on a ventilator, in any intensive care or step-down unit, who are given a sedation vacation every 24 hours

x (TEST MEASURE)

x

Rapid Response Teams

x

Medication Reconciliation

x

x

Preventing Central Line Infections

CMS-QIO

* APU

** HQA

JCAHO

IHI

GWTG

Hand Hygiene

x

Maximal Barrier Precautions

x

Chlorhexidine Skin Antisepsis

x

Appropriate CatheterSite and Administration System Care

x

No Routine Replacement

x

NOTES:

* The original 10 core measures are under APU

** The expanded set of 22 measures are under HQA

1 = Began with patients discharged 2Q '04, hospital compare 1Q '05.

2 = Began with patients discharged 3Q '04, hospital compare 9/05.

3 = Began with patients discharged 3Q '04.

4 = Began with ICU patients admitted 7/05.

Publication No. 4020-OH-066-6/2005. This material was prepared by Ohio KePRO, the Medicare Quality Improvement Organization for Ohio, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.