1. No category

Last Updated: Version 4.3
ACUTE MYOCARDIAL INFARCTION NATIONAL HOSPITAL INPATIENT QUALITY
MEASURES
Set
Measure
ID #
Measure Short Name
AMI-1
Aspirin at Arrival
AMI-2
Aspirin Prescribed at Discharge
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
Primary PCI Received Within 90 Minutes of Hospital Arrival
AMI-10
Statin Prescribed at Discharge
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
AMI-1
Last Updated: Version 4.3
HEART FAILURE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES
Set
Measure
ID #
Measure Short Name
HF-1
Discharge Instructions
HF-2
Evaluation of LVS Function
HF-3
ACEI or ARB for LVSD
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
HF-1
Last Updated: Version 4.3
PNEUMONIA NATIONAL HOSPITAL INPATIENT QUALITY MEASURES
Set
Measure
ID #
PN-3a
PN-3b
Measure Short Name
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
Blood Cultures Performed in the Emergency Department Prior to Initial
Antibiotic Received in Hospital
PN-6
Initial Antibiotic Selection for CAP in Immunocompetent Patient
PN-6a
Initial Antibiotic Selection for CAP in Immunocompetent – ICU Patient
PN-6b
Initial Antibiotic Selection for CAP Immunocompetent – Non ICU Patient
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
PN - 1
Last Updated: Version 4.3
SURGICAL CARE IMPROVEMENT PROJECT NATIONAL HOSPITAL INPATIENT
QUALITY MEASURES
Set
Measure
ID #
SCIP-Inf-1a
SCIP-Inf-1b
SCIP-Inf-1c
SCIP-Inf-1d
SCIP-Inf-1e
SCIP-Inf-1f
SCIP-Inf-1g
SCIP-Inf-1h
Measure Short Name
Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision - Overall Rate
Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision - CABG
Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision - Other Cardiac Surgery
Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision - Hip Arthroplasty
Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision - Knee Arthroplasty
Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision - Colon Surgery
Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision - Hysterectomy
Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision - Vascular Surgery
SCIP-Inf-2a
Prophylactic Antibiotic Selection for Surgical Patients - Overall Rate
SCIP-Inf-2b
Prophylactic Antibiotic Selection for Surgical Patients - CABG
SCIP-Inf-2c
SCIP-Inf-2d
SCIP-Inf-2e
Prophylactic Antibiotic Selection for Surgical Patients - Other Cardiac
Surgery
Prophylactic Antibiotic Selection for Surgical Patients - Hip
Arthroplasty
Prophylactic Antibiotic Selection for Surgical Patients - Knee
Arthroplasty
SCIP-Inf-2f
Prophylactic Antibiotic Selection for Surgical Patients - Colon Surgery
SCIP-Inf-2g
Prophylactic Antibiotic Selection for Surgical Patients - Hysterectomy
SCIP-Inf-2h
Prophylactic Antibiotic Selection for Surgical Patients - Vascular
Surgery
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
SCIP-1
Set
Measure
ID #
SCIP-Inf-3a
SCIP-Inf-3b
SCIP-Inf-3c
SCIP-Inf-3d
SCIP-Inf-3e
SCIP-Inf-3f
SCIP-Inf-3g
SCIP-Inf-3h
SCIP-Inf-4
Measure Short Name
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time - Overall Rate
Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery
End Time – CABG
Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery
End Time - Other Cardiac Surgery
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time - Hip Arthroplasty
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time - Knee Arthroplasty
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time - Colon Surgery
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time – Hysterectomy
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time - Vascular Surgery
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
SCIP-Inf-10
Surgery Patients with Perioperative Temperature Management
Set
Measure ID #
Cardiac
SCIP-Card-2
Measure Short Name
Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who
Received a Beta-Blocker During the Perioperative Period
Set
Measure ID #
VTE
Measure Short Name
SCIP-VTE-2
Surgery Patients Who Received Appropriate Venous
Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24
Hours After Surgery
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
SCIP-2
Last Updated: Version 4.3
CHILDREN’S ASTHMA CARE NATIONAL HOSPITAL INPATIENT QUALITY
MEASURES
Set
Measure
ID#
Measure Short Names
CAC-1a
Relievers for Inpatient Asthma (age 2 through 17 years) – Overall Rate
CAC-1b
Relievers for Inpatient Asthma (age 2 through 4 years)
CAC-1c
Relievers for Inpatient Asthma (age 5 through 12 years)
CAC-1d
Relievers for Inpatient Asthma (age 13 through 17 years)
CAC-2a
Systemic Corticosteroids for Inpatient Asthma (age 2 through 17 years)
– Overall Rate
CAC-2b
Systemic Corticosteroids for Inpatient Asthma (age 2 through 4 years)
CAC-2c
Systemic Corticosteroids for Inpatient Asthma (age 5 through 12 years)
CAC-2d
Systemic Corticosteroids for Inpatient Asthma (age 13 through 17 years)
CAC-3
Home Management Plan of Care (HMPC) Document Given to
Patient/Caregiver
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
CAC-1
Last Updated: Version 4.3
VENOUS THROMBOEMBOLISM NATIONAL HOSPITAL INPATIENT QUALITY
MEASURES
Set
Measure
ID #
Measure Short Name
VTE-1
Venous Thromboembolism Prophylaxis
VTE-2
VTE-4
Intensive Care Unit Venous Thromboembolism Prophylaxis
Venous Thromboembolism Patients with Anticoagulation Overlap
Therapy
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
VTE-3
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
VTE-1
Last Updated: Version 4.3
STROKE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES
Set
Measure
ID #
Measure Short Name
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
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
STK-1
Last Updated: Version 4.0a
Global National Hospital Inpatient Quality Measures
Global Initial Patient Population
Global is an umbrella name for four measure sets, Emergency Department (ED),
Immunization (IMM), Substance Use (SUB) and Tobacco Treatment (TOB).
The purpose of defining an umbrella name was to apply one population flow and one
sampling on the Global population and reduce the burden of sampling for four measure
sets or any number of these four measure sets that are selected.
Therefore, if only two of the Global measure sets are selected and reported, the process
would only apply for those two measure sets.
The Global Initial Patient Population is defined by two data elements:
•
Admission Date
•
Discharge Date
All patients discharged from acute inpatient care with Length of Stay (Discharge Date
minus Admission Date) less than or equal to 120 days are included in the Global Initial
Population and are eligible for sampling.
The cases that are accepted into the Global Initial patient population and are sampled
would be selected for the specific measure set and return to the Transmission Data
Processing Flow: Clinical in the Data Transmission section.
Hospitals must submit the same case for all applicable measure sets (i.e., ED, IMM,
SUB and TOB) under the Global Initial Patient Population. Example:
•
For every ED case that is submitted to the QIO Clinical Warehouse the same
case must also be submitted as an IMM case to the QIO Clinical Warehouse.
•
If a hospital has elected to submit ED, TOB and IMM to The Joint Commission,
for every ED case that is submitted the same case must also be submitted as a
TOB case and an IMM case to The Joint Commission’s Data Warehouse. The
same holds true regardless of the combination of measure sets (ED, IMM, SUB,
TOB) the hospital has elected to submit to The Joint Commission.
The Global Initial Patient Population only contains the population information and flow.
There is no measure associated to Global; therefore there is no measure flow or MIF for
Global.
For Emergency Department (ED), Immunization (IMM), Substance Use (SUB) and
Tobacco Treatment (TOB) Initial Patient Population definitions, please refer to the
Global Initial Patient Population.
For Emergency Department, Immunization, Substance Use and Tobacco Treatment
Initial Patient Population Algorithms please refer to the Global Initial Patient Population
Algorithm.
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
GBL-1
Last Updated: Version 4.3
EMERGENCY DEPARTMENT NATIONAL HOSPITAL INPATIENT QUALITY
MEASURES
Set
Measure
ID #
ED-1a
ED-1b
ED-1c
ED-2a
ED-2b
ED-2c
Measure Short Name
Median Time from ED Arrival to ED Departure for Admitted ED Patients
– Overall Rate
Median Time from ED Arrival to ED Departure for Admitted ED Patients
– Reporting Measure
Median Time from ED Arrival to ED Departure for Admitted ED Patients
– Psychiatric/Mental Health Patients
Admit Decision Time to ED Departure Time for Admitted Patients –
Overall Rate
Admit Decision Time to ED Departure Time for Admitted Patients –
Reporting Measure
Admit Decision Time to ED Departure Time for Admitted Patients –
Psychiatric/Mental Health Patients
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
ED-1
Last Updated: Version 4.3
IMMUNIZATION NATIONAL HOSPITAL INPATIENT QUALITY MEASURES
Set
Measure
ID#
Measure Short Name
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
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
IMM-1
Last Updated: Version 4.3
TOBACCO TREATMENT NATIONAL HOSPITAL INPATIENT QUALITY MEASURES
Collected for: The Joint Commission Only
CMS Informational Only
Set
Measure
ID #
Measure Short Name
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
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
TOB-1
Last Updated: Version 4.3
SUBSTANCE USE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES
Collected For: The Joint Commission Only
CMS Informational Only
Set
Measure
ID#
Measure Short Name
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
Specifications Manual for National Hospital Inpatient Quality Measures
Discharges 01-01-14 (1Q14) through 09-30-14 (3Q14)
SUB-1