Measuresheets

Inpatient Quality Reporting (IQR) Hospital Measures

KEY HOSPITAL MEASURES - HOSPITAL INPATIENT QUALITY REPORTING (IQR) MEASURE ID BI-CLINICAL COVERAGE
Acute Myocardial Infarction (AMI)
Aspirin at Arrival AMI-1 YES
Aspirin prescribed at Discharge AMI-2 YES
ACEI or ARB for LVSD AMI-3 YES
Beta Blocker prescribed at Discharge AMI-5 YES
Fibrinolysis Therapy Received Within 30 Minutes of Hospital Arrival AMI-7a YES
Primary PCI Received Within 90 Minutes of Hospital Arrival AMI-8a YES
Statin prescribed at discharge AMI-10  
Heart Failure (HF) Hospital Measures
Discharge Instructions HF-1 YES
Evaluation of LVS function HF-2 YES
ACEI or ARB for LVSD HF-3  
Pneumonia (PN) Hospital Measures
Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital PN-3B YES
Initial Antibiotic Selection for CAP in Immunocompetent Patient (Composite) PN-6 YES
Surgical Care Improvement Project (SCIP)
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision (Composite) SCIP-Inf-1 (a-h) YES
Prophylactic Antibiotic Selection for Surgical Patients (Composite) SCIP-Inf-2 (a-h) YES
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time (Composite) SCIP-Inf-3 (a-h) YES
Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose SCIP-Inf-4 YES
Surgery Patients with Appropriate Hair Removal SCIP-Inf-6 YES
Urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero SCIP-Inf-9 YES
Surgery Patients with Perioperative Temperature Management SCIP-Inf-10 YES
Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period SCIP-Card-2 YES
Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered SCIP-VTE-1 YES
Surgery Patients Who Received Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24Hours After Surgery SCIP-VTE-2 YES
Emergency Department (ED) Hospital Measures
Median Time from ED Arrival to ED Departure for Admitted ED Patients (Composite) ED-1(a-d) YES
Admit Decision Time to ED Departure Time for Admitted Patients (Composite) ED-1(a-c) YES
Immunization (IMM) Hospital Measures
Pneumococcal Immunization (PPV23) (Composite) IMM-1(a-c) YES
Influenza Immunization IMM-2 YES
Hospital Acquired Infections (HAI)
Central Line-Associated Bloodstream Infection CLASBSI YES
Surgical Site Infection SSI YES
Catheter-Associated Urinary Tract Infection CAUTI YES
Risk-Standardized Mortality Rate (RSMR)
Hospital 30-day all-cause RSMR following hospitalization for AMI MORT-30-AMI YES
Hospital 30-day all-cause RSMR following hospitalization for Heart Failure MORT-30-HF YES
Hospital 30-day all-cause RSMR following hospitalization for Pneumonia MORT-30-PN YES
Risk-Standardized Readmission Rate (RSRR)
Hospital 30-day all-cause RSRR following hospitalization for AMI READM-30-AMI YES
Hospital 30-day all-cause RSRR following hospitalization for Heart Failure READM-30-HF YES
Hospital 30-day all-cause RSRR following hospitalization for Pneumonia READM-30-PN YES
AHRQ Patient Safety Indicators (PSI)
Death among surgical inpatients with serious, treatable complications PSI-04 YES
Iatrogenic pneumothorax, adult PSI-06 YES
Post-Operative Respiratory Failure PSI-11 YES
Post-Operative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) PSI-12 YES
Postoperative wound dehiscence PSI-14 YES
Accidental puncture or laceration PSI-15 YES
PSI Complication/patient safety for selected indicators (composite) PSI-Comp YES
AHRQ Inpatient Quality Indicators (IQI)
IQI 11 - Abdominal aortic aneurysm (AAA) mortality rate with volume IQI-11 YES
IQI 19 - Hip fracture mortality rate IQI-19 YES
IQI Mortality for selected medical conditions (composite) IQI-Comp YES
Hospital Acquired Conditions HAC)
Foreign object retained after surgery HAC-1 YES
Air embolism HAC-2 YES
Blood incompatibility HAC-3 YES
Pressure ulcer stages III and IV HAC-4 YES
Falls and trauma HAC-5 YES
Vascular catheter-associated Infection HAC-6 YES
Catheter-associated urinary tract infections HAC-7 YES
Manifestations of poor glycemic control HAC-8 YES