|
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 |