Encyclopedia of Measures (EOM) - K-HIIN · Encyclopedia of Measures (EOM) Core Adverse Event Area ... for hospitals conferring rights to AHA/HRET HEN 2.0 group ... HEN2-ADE-2b AHA/HRET

AHA/HRET HEN 2.0

Encyclopedia of Measures (EOM) Core Adverse Event Area (AEA) Process Measures Version 1.0 Last updated: 12/18/2015

Summary of 12/18/2015 Updates

Initial release

AHA/HRET HEN 2.0

Core Process EOM HEN 2.0, v1.0 Last update: 12/18/2015 2

2

Contents

Hand-Hygiene Adherence Rate (All Infection Topics) .............................................................................. 4

Adverse Drug Event (ADE) Venous Thromboembolism Warfarin Therapy Discharge Instructions .......... 5

Reconciled Medication List Received by Discharged Patients ................................................................. 6

Adverse Drug Event (ADE) Hypoglycemia Monitoring ............................................................................. 7

Adverse Drug Event (ADE): Opioid Risk Assessment ............................................................................... 8

Adverse Drug Event (ADE) Formal Assessment during Opioid Therapy ................................................... 9

Urinary Catheter Removed in a Timely Manner .................................................................................... 10

Central-Line-Bundle-Compliance Composite ......................................................................................... 11

Daily Review of Central-Line Necessity ................................................................................................. 12

Central-Line-Maintenance-Bundle Compliance (All-or-None Bundle) ................................................... 13

Assessment of Fall Risk ......................................................................................................................... 14

Fall Risk Assessment ............................................................................................................................. 15

Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls ......................................... 16

Suspected Preeclampsia Algorithm ....................................................................................................... 17

Obstetrical Hemorrhage Risk Assessment on Admission ...................................................................... 18

Patients at Risk for Pre-Term Delivery Receiving Antenatal Steroids .................................................... 19

Patients with Skin Assessment Documented Within 4 Hours of Admission .......................................... 20

Patients with Pressure Ulcer Risk Assessment Completed within 24 hours of Admission ..................... 21

Documentation of Compliance with Prevention Interventions ............................................................. 22

Care-Transition-Bundle Compliance ...................................................................................................... 23

Completion of Discharge Bundle (Project BOOST) ................................................................................ 24

Completion of Patient Care Plan (Project RED) ..................................................................................... 25

Formal Assessment of Patient's Risk of Readmission (BOOST).............................................................. 26

Patients Receiving Complete Discharge Education Verified by Teach-Back or Other Means (Project Red /

BOOST) .................................................................................................................................................. 27

Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision ........................................ 28

Prophylactic Antibiotic Selection for Surgical Patients .......................................................................... 29

Prophylactic Antibiotics Discontinued within 24 Hours after Surgery End Time ................................... 30

AHA/HRET HEN 2.0


3

ABCDEF Bundle Compliance .................................................................................................................. 31

Spontaneous Awakening Trial Rate....................................................................................................... 32

Spontaneous Breathing Trial Rate ......................................................................................................... 33

Venous Thromboembolism Prophylaxis ................................................................................................ 34

Surgery Patients who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to

Surgery to 24 Hours after Surgery ......................................................................................................... 35

Venous Thromboembolism Warfarin Therapy Discharge Instructions .................................................. 36

AHA/HRET HEN 2.0


4

Hand-Hygiene Adherence Rate (All Infection Topics)

Infection Topics: HEN Process Measure

Hand hygiene consistent with recommended guidelines

Measure type Process

Numerator Hand hygiene performed consistent with guidelines

Denominator Total number of hand-hygiene observation opportunities

Calculation (Total number of acts of hand hygiene consistent with guidelines / Total number of observed hand-hygiene opportunities) * 100

Specifications/definitions Sources/Recommendations

Available from The Joint Commission. Hand hygiene should be monitored according to the NHSN protocols.

Data source (s) NHSN

NHSN data transfer Yes - for hospitals conferring rights to AHA/HRET HEN 2.0 group

Baseline period Jul - Sep 2015

Monitoring period Monthly, beginning Oct 2015

CDS Measure ID(s) HEN2-HAND-1

AHA/HRET HEN 1 EOM-CAUTI-17

This process measure is applicable to all core infection topics: CAUTI, CLABSI, and SSI. Additional references: The Partnership for Patients has gathered many resources for ADE prevention and measurement. These resources are catalogued online at the following link: https://partnershipforpatients.cms.gov/p4p_resources/tsp-adversedrugevents/tooladversedrugeventsade.html

http://www.jointcommission.org/assets/1/18/hh_monograph.pdf

http://www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf

https://partnershipforpatients.cms.gov/p4p_resources/tsp-adversedrugevents/tooladversedrugeventsade.html


AHA/HRET HEN 2.0


5

Adverse Drug Event (ADE) Venous Thromboembolism Warfarin Therapy Discharge Instructions

ADE: HEN Process Measure – NQF 0375 (VTE-5)

Adverse Drug Event (ADE) Venous Thromboembolism (VTE) Warfarin Therapy Discharge Instructions


Numerator

Patients diagnosed with confirmed VTE who are discharged (to home, home care, home hospice care, or court/law enforcement) on warfarin with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin that addressed all CMS-designated issues

Denominator Patients diagnosed with confirmed VTE who are discharged (to home, home care, home hospice care, or court/law enforcement) on warfarin

Calculation 𝑁𝑢𝑚𝑒𝑟𝑎𝑡𝑜𝑟

𝐷𝑒𝑛𝑜𝑚𝑖𝑛𝑎𝑡𝑜𝑟∗ 100


Available from CMS (Section 2.6)

Data source (s) Chart

NHSN data transfer No


Monitoring period Monthly starting October 2015

CDS Measure ID(s) HEN2-ADE-2a

AHA/HRET HEN 1 NOT COLLECTED

Additional References: The Partnership for Patients has gathered many resources for ADE prevention and measurement. These resources are catalogued online at the following link: https://partnershipforpatients.cms.gov/p4p_resources/tsp-adversedrugevents/tooladversedrugeventsade.html

http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228774725171



AHA/HRET HEN 2.0


6

Reconciled Medication List Received by Discharged Patients

ADE: HEN Process Measure – NQF 0646

Reconciled medication list received by discharged patients


Numerator

Patients who were discharged who received (or their caregiver(s) received) a reconciled medication list at the time of discharge, including, at a minimum, medications to be TAKEN by patient and medications NOT to be taken by patient

Denominator All patients, regardless of age, discharged from an inpatient facility




Available from the American Medical Association





CDS Measure ID(s) HEN2-ADE-2b

AHA/HRET HEN 1 EOM-ADE-6


http://www.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI



AHA/HRET HEN 2.0


7

Adverse Drug Event (ADE) Hypoglycemia Monitoring

ADE: HEN Process Measure

Percentage of patients on insulin whose blood sugars registered <80 mg/dl at least once


Numerator Number of patients on insulin whose blood sugar registered <80 mg/dl at least once

Denominator Total number of patients on insulin




Available from the American Diabetes Association





CDS Measure ID(s) HEN2-ADE-2c



http://care.diabetesjournals.org/content/38/Supplement_1/S33.full.pdf+html?sid=7bdec8de-a9f2-4f65-9ba0-3a12b9227ba4



AHA/HRET HEN 2.0


8

Adverse Drug Event (ADE): Opioid Risk Assessment


Percentage of patients receiving opioids who receive an opioid risk assessment prior to first opioid dose


Numerator Number of patients on opioids who received an opioid risk assessment prior to first opioid dose

Denominator Total number of patients on opioids




Available from the Oregon Pain Guidance





CDS Measure ID(s) HEN2-ADE-2d



http://www.southernoregonopioidmanagement.org/app/content/uploads/2014/04/OPG_Guidelines.pdf



AHA/HRET HEN 2.0


9

Adverse Drug Event (ADE) Formal Assessment during Opioid Therapy


Percentage of patients receiving opioids who regularly receive a formal assessment (e.g., POSS or RASS) during therapy


Numerator Number of patients receiving opioids who regularly receive a formal assessment (e.g., POSS or RASS) during therapy

Denominator Total number of patients on opioids




Available from the Minnesota Hospital Association





CDS Measure ID(s) HEN2-ADE-2e


Additional References: A comparison of POSS and RASS assessments can be found on the Anne Arundel Health System website at the following link: http://www.aahs.org/aamcnursing/wp-content/uploads/Opioid-Sedation-Comparison-Study.pdf The Partnership for Patients has gathered many resources for ADE prevention and measurement. These resources are catalogued online at the following link: https://partnershipforpatients.cms.gov/p4p_resources/tsp-adversedrugevents/tooladversedrugeventsade.html

http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Gap-Analysis-Opioid.pdf

http://www.aahs.org/aamcnursing/wp-content/uploads/Opioid-Sedation-Comparison-Study.pdf



AHA/HRET HEN 2.0


10

Urinary Catheter Removed in a Timely Manner

CAUTI: HEN Process Measure - NQF 0453 (SCIP-INF-9)

Percentage of surgery patients whose urinary catheters were removed on the first or second day after surgery


Numerator Number of surgical patients whose urinary catheter is removed on post-operative day 1 or 2, with day of surgery being day zero

Denominator All selected surgical patients with a catheter in place postoperatively




Available from CMS





CDS Measure ID(s) HEN2-CAUTI-4a

AHA/HRET HEN 1 EOM-CAUTI-15

Additional references: The Partnership for Patients has also gathered many resources for CAUTI prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-catheterassociatedurinarytractinfections/toolcatheter-associatedurinarytractinfectionscauti.html


http://partnershipforpatients.cms.gov/p4p_resources/tsp-catheterassociatedurinarytractinfections/toolcatheter-associatedurinarytractinfectionscauti.html

http://partnershipforpatients.cms.gov/p4p_resources/tsp-catheterassociatedurinarytractinfections/toolcatheter-associatedurinarytractinfectionscauti.html

AHA/HRET HEN 2.0


11

Central-Line-Bundle-Compliance Composite

CLABSI: HEN Process Measure - NQF 0298

Percentage of intensive-care patients with central lines for whom all elements of the central-line bundle are documented and in place.


Numerator Number of intensive-care patients with central lines for whom all elements of the central-line bundle are documented and in place

Denominator Total number of intensive-care patients with central lines on the day of sample.




Available from the Institute for Healthcare Improvement





CDS Measure ID(s) HEN2-CLABSI-4a


Additional references: The CDC has developed numerous resources for CLABSI surveillance, definitions, data collection and reporting. These resources are available online, at the following link: http://www.cdc.gov/nhsn/acute-care-hospital/CLABSI/index.html The Partnership for Patients has also gathered many resources for CLABSI prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-centralline-associatedbloodstreaminfections/toolcentralline-associatedbloodstreaminfectionsclabsi.html

http://www.ihi.org/Topics/CentralLineInfection/Pages/default.aspx

http://www.cdc.gov/nhsn/acute-care-hospital/CLABSI/index.html


http://partnershipforpatients.cms.gov/p4p_resources/tsp-centralline-associatedbloodstreaminfections/toolcentralline-associatedbloodstreaminfectionsclabsi.html


AHA/HRET HEN 2.0


12

Daily Review of Central-Line Necessity

CLABSI: HEN Process Measure

Compliance with the daily review of central-line necessity


Numerator Number of patients with a central line who had a daily review of central-line necessity

Denominator Total number of patients with a central line




Available from The Joint Commission





CDS Measure ID(s) HEN2-CLABSI-4b

AHA/HRET HEN 1 EOM-CLABSI-127

Additional references: The CDC has developed numerous resources for CLABSI surveillance, definitions, data collection and reporting. These resources are available online, at the following link: http://www.cdc.gov/nhsn/acute-care-hospital/CLABSI/index.html The Partnership for Patients has also gathered many resources for CLABSI prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-centralline-associatedbloodstreaminfections/toolcentralline-associatedbloodstreaminfectionsclabsi.html

http://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-22_CVC_Maintenance_Bundles.pdf





AHA/HRET HEN 2.0


13

Central-Line-Maintenance-Bundle Compliance (All-or-None Bundle)

CLABSI: HEN Process Measure

Central-Line-Maintenance-Bundle Compliance (all-or-none bundle-element compliance)


Numerator Number of audited patients for whom all bundle components were met (full compliance with hospital-defined bundle).

Denominator Total number of patients with a central line









CDS Measure ID(s) HEN2-CLABSI-4c

AHA/HRET HEN 1 EOM-CLABSI-129

Additional references: The CDC has developed numerous resources for CLABSI surveillance, definitions, data collection and reporting. These resources are available online at the following link: http://www.cdc.gov/nhsn/acute-care-hospital/CLABSI/index.html The Partnership for Patients has also gathered many resources for CLABSI prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-centralline-associatedbloodstreaminfections/toolcentralline-associatedbloodstreaminfectionsclabsi.html

http://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-22_CVC_Maintenance_Bundles.pdf





AHA/HRET HEN 2.0


14

Assessment of Fall Risk

Falls: HEN Process Measure

Patients that were assessed for risk of falls


Numerator Patients that were assessed using the Algorithm for Fall Risk Assessment & Interventions within 24 hours of admission

Denominator All patients




Available from the Centers for Disease Control and Prevention





CDS Measure ID(s) HEN2-Falls-2a


Additional references: The Agency for Healthcare Research & Quality (AHRQ) has developed a comprehensive resource for measuring fall rates and fall-prevention practices. The resource is available online at the following link: http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html The American Nurses Association (ANA) has published an article about measuring fall-program outcomes. The article is available online at the following link: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No2May07/ArticlePreviousTopic/MeasuringFallProgramOutcomes.html The Partnership for Patients has also gathered many resources for injuries from falls and immobility. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-injuriesandfallsfromimmobility/toolinjuriesandfallsfromimmobility.html

http://www.cdc.gov/steadi/materials.html

http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No2May07/ArticlePreviousTopic/MeasuringFallProgramOutcomes.html


http://partnershipforpatients.cms.gov/p4p_resources/tsp-injuriesandfallsfromimmobility/toolinjuriesandfallsfromimmobility.html


AHA/HRET HEN 2.0


15

Fall Risk Assessment

Falls: HEN Process Measure - NQF#0035

Percentage of patients for which two-part fall risk management is completed. Numerators and denominators should be aggregated for reporting to AHA/HRET.


Numerator

A. Number of patients who reported that fall risk was discussed with them, AND B. Number of patients who reported they received fall risk management intervention.

Denominator

A1. Adults age 75 and older who had a provider visit in the past

12 months

A2. Adults age 65-74 who had a provider visit in the past 12

months and report either falling or having a problem with

balance or walking in the past 12 months.

B. Adults age 65 and older who had a provider visit in the past

12 months and report either falling or having a problem with

balance or walking in the past 12 months.




Available from National Committee for Quality Assurance

Data source (s) Patients, charts




CDS Measure ID(s) HEN2-FALLS-2a


Additional references: The Agency for Healthcare Research & Quality (AHRQ) has developed a comprehensive resource for measuring fall rates and fall prevention practices. The resource is available online at the following link: http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html The American Nurses Association (ANA) has published an article about measuring fall program outcomes. The article is available online at the following link: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No2May07/ArticlePreviousTopic/MeasuringFallProgramOutcomes.html

http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality/2015TableofContents/FallRisk.aspx




AHA/HRET HEN 2.0


16

Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls

Falls: HEN Process Measure -- NQF# 0101

Three-part assessment of falls prevention in older adults. Numerators and denominators should be aggregated for reporting to AHA/HRET.


Numerator

A. Number of patients aged 65 years of age and older who were screened for future fall risk at least once within 12 months B. Number of patients aged 65 years of age and older with a history of falls who had a plan of care for falls documented within 12 months. C. Number of patients aged 65 years of age and older with a history of falls who had a risk assessment for falls completed within 12 months

Denominator

A. All patients aged 65 years and older. B and C. All patients aged 65 years and older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year).




Available from NCQA





CDS Measure ID(s) HEN2-FALLS-2b


Additional references: The Agency for Healthcare Research & Quality (AHRQ) has developed a comprehensive resource for measuring fall rates and fall prevention practices. The resource is available online at the following link: http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html The Partnership for Patients has also gathered many resources for injuries from falls and immobility. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-injuriesandfallsfromimmobility/toolinjuriesandfallsfromimmobility.html

http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality/2015TableofContents/FallRisk.aspx




AHA/HRET HEN 2.0


17

Suspected Preeclampsia Algorithm

Obstetrical Adverse Events: HEN Process Measure

Percentage of women that are assessed for preeclampsia on admission


Numerator Number of women admitted to labor and delivery who have an assessment for preeclampsia using the suspected preeclampsia algorithm recorded in their medical record

Denominator Number of women admitted to labor and delivery




Available from the California Maternal Quality Care Collaborative





CDS Measure ID(s) HEN2-OB-5a


Additional references: The California Maternal Quality Care Collaborative (CMQCC) has developed a comprehensive toolkit addressing obstetric hemorrhage. The resources are available on the CMQCC website, at the following link: https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit The Partnership for Patients has also gathered many resources for obstetrical adverse event and prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-obstetricaladverseevents/toolobstetricaladverseevents.html

https://www.cmqcc.org/resources-tool-kits


https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit

http://partnershipforpatients.cms.gov/p4p_resources/tsp-obstetricaladverseevents/toolobstetricaladverseevents.html


AHA/HRET HEN 2.0


18

Obstetrical Hemorrhage Risk Assessment on Admission

Obstetrical Adverse Events: HEN Process Measure

Percentage of women who are assessed for risk of obstetric (OB) hemorrhage on admission


Numerator Number of women admitted to labor and delivery whose risk of OB hemorrhage is recorded in the medical record

Denominator Number of women admitted to labor and delivery




Available from the California Maternal Quality Care Collaborative





CDS Measure ID(s) HEN2-OB-5b

AHA/HRET HEN 1 EOM-OB AE-116

Additional references: The California Maternal Quality Care Collaborative (CMQCC) has developed a comprehensive toolkit addressing obstetric hemorrhage. The resources are available on the CMQCC website, at the following link: https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit The Partnership for Patients has also gathered many resources for obstetrical adverse event and prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-obstetricaladverseevents/toolobstetricaladverseevents.html



https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit



AHA/HRET HEN 2.0


19

Patients at Risk for Pre-Term Delivery Receiving Antenatal Steroids

Obstetrical Adverse Events: HEN Process Measure -- NQF 0476 (JC PC-03)

Percentage of patients at risk of pre-term delivery at 24-32 weeks gestation receiving antenatal steroids prior to delivering pre-term newborns


Numerator Patients with a full course of antenatal steroids completed prior to delivering pre-term newborns

Denominator Patients delivering live pre-term newborns with 24 0/7 – 32 0/7 weeks gestation completed









CDS Measure ID(s) HEN2-OB-5c

AHA/HRET HEN 1 EOM-OB AE-41

Additional references: The Partnership for Patients has also gathered many resources for obstetrical adverse event and prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-obstetricaladverseevents/toolobstetricaladverseevents.html

https://manual.jointcommission.org/releases/TJC2015B2/PerinatalCare.html



AHA/HRET HEN 2.0


20

Patients with Skin Assessment Documented Within 4 Hours of Admission

PRU: HEN Process Measure

Percentage of patients with skin assessment documented within 24 hours of admission


Numerator Inpatients with timely, complete skin assessment

Denominator All inpatients admitted to hospital or unit under surveillance

Calculation

𝑁𝑢𝑚𝑒𝑟𝑎𝑡𝑜𝑟



Available from AHRQ

Data source (s) Chart, Unit Log




CDS Measure ID(s) HEN2-PrU-3a

AHA/HRET HEN 1 EOM-PrU-136

Additional references: The AHRQ has developed a comprehensive resource for measuring pressure ulcer rates and prevention practices. The resource is available online at the following link: http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool5.html The Partnership for Patients has also gathered many resources for pressure ulcer prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-pressureulcers/toolpressureulcers.html

http://www.ahrq.gov/sites/default/files/publications/files/putoolkit.pdf

http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool5.html

http://partnershipforpatients.cms.gov/p4p_resources/tsp-pressureulcers/toolpressureulcers.html

AHA/HRET HEN 2.0


21

Patients with Pressure Ulcer Risk Assessment Completed within 24 hours of Admission


The percentage of patients that have a pressure ulcer assessment completed within 24 hours of admission


Numerator Number of inpatients with documentation in medical record of a complete pressure-ulcer risk assessment

Denominator All inpatients admitted to hospital or unit under surveillance




Available from AHRQ

Data source (s) Charts, Unit Logs




CDS Measure ID(s) HEN2-PrU-3b


Additional references: The AHRQ has developed a comprehensive resource for measuring pressure ulcer rates and prevention practices. The resource is available online at the following link: http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool5.html The Partnership for Patients has also gathered many resources for pressure ulcer prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-pressureulcers/toolpressureulcers.html




AHA/HRET HEN 2.0


22

Documentation of Compliance with Prevention Interventions


Percentage of documented prevention interventions for patients assessed at risk for a pressure ulcer


Numerator Number of patients with documented pressure-ulcer prevention interventions after assessed as at risk for a pressure ulcer.

Denominator Total number of patients assessed as at risk for a pressure ulcer (may be sampled)




Available from AHRQ





CDS Measure ID(s) EOM-PrU-3c


Additional references: The AHRQ has developed a comprehensive resource for measuring pressure ulcer rates and prevention practices. The resource is available online at the following link: http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool5.html The Partnership for Patients has also gathered many resources for pressure-ulcer prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-pressureulcers/toolpressureulcers.html




AHA/HRET HEN 2.0


23

Care-Transition-Bundle Compliance

Readmissions: HEN Process Measure

Compliance in implementing the seven essential elements of the caretransitions bundle


Numerator Number of patients for which all seven elements of the care-transitions bundle were implemented

Denominator All eligible patients




Available from the National Transition of Care Coalition





CDS Measure ID(s) HEN2-READ-2a


Additional references: The Partnership for Patients has also gathered many resources for readmissions prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-preventablereadmissions/toolpreventablereadmissions.html

http://www.ntocc.org/Portals/0/PDF/Compendium/SevenEssentialElements_NTOCC%20logo.pdf

http://partnershipforpatients.cms.gov/p4p_resources/tsp-preventablereadmissions/toolpreventablereadmissions.html


AHA/HRET HEN 2.0


24

Completion of Discharge Bundle (Project BOOST)

Readmissions: CMS HEN Process Measure

Percentage of discharge care plans that contain all the elements of the discharge care plan


Numerator Number of discharge care plans with all elements present

Denominator Number of discharge care plans




Available from The Society of Hospital Medicine





CDS Measure ID(s) HEN2-READ-2b

AHA/HRET HEN 1 EOM-Readmission-64


http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx



AHA/HRET HEN 2.0


25

Completion of Patient Care Plan (Project RED)


Percentage of Project RED patient care plans that contain all the elements of the Project RED patient care plan


Numerator Number of Project RED patient care plans that contain all the elements of the Project RED patient care plan

Denominator Total number of care plans reviewed




Available from AHRQ





CDS Measure ID(s) HEN2-READ-2c



http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html



AHA/HRET HEN 2.0


26

Formal Assessment of Patient's Risk of Readmission (BOOST)

Readmissions: CMS HEN Process Measure

Percentage of risk assessment tool is completed at admission


Numerator Number of patients who have risk of readmission assessed using standard tool (e.g., TARGET Assessment 8P scale or similar)





Available from The Society of Hospital Medicine





CDS Measure ID(s) HEN2-READ-2d



http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/BOOST_Intervention/Tools/Risk_Assessment.aspx



AHA/HRET HEN 2.0


27

Patients Receiving Complete Discharge Education Verified by Teach-Back or Other Means (Project

Red / BOOST)


Percentage of patients receiving complete discharge education verified by teach-back or other means


Numerator Patients receiving complete discharge education verified by teach-back or other means





Available from The Society of Hospital Medicine / AHRQ





CDS Measure ID(s) HEN2-READ-2e



http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/Teach_Back_Process_2.pdfhttp:/www.bu.edu/fammed/projectred/newtoolkit/3.%20How%20to%20deliver%20the%20RED%204.15.11.pdf



AHA/HRET HEN 2.0


28

Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision

SSI: HEN Process Measure - NQF 0527 (SCIP-Inf-1a)

Percentage of surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection


Numerator Number of surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision (two hours if receiving vancomycin or fluoroquinolone)

Denominator All selected surgical patients with no evidence of prior infection




Available from CMS





CDS Measure ID(s) HEN2-SSI-3a

AHA/HRET HEN 1 EOM-SSI-83

Additional references: The Partnership for Patients has gathered many resources for SSI prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-surgicalsiteinfections/toolsurgicalsiteinfections.html


http://partnershipforpatients.cms.gov/p4p_resources/tsp-surgicalsiteinfections/toolsurgicalsiteinfections.html


AHA/HRET HEN 2.0


29

Prophylactic Antibiotic Selection for Surgical Patients

SSI: HEN Process Measure - NQF 0528 (SCIP-Inf-2a)

Surgery patients who were given the right kind of antibiotic to help prevent infection


Numerator Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure

Denominator All selected surgical patients with no evidence of prior infection




Available from CMS





CDS Measure ID(s) HEN2-SSI-3b






AHA/HRET HEN 2.0


30

Prophylactic Antibiotics Discontinued within 24 Hours after Surgery End Time

SSI: HEN Process Measure - NQF 0529 (SCIP-INF-3a)

Percentage of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after anesthesia end time.


Numerator

Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after anesthesia end time (48 hours for coronary artery bypass grafting [CABG] or other cardiac surgery).

Denominator All selected surgical patients with no evidence of prior infection.




Available from CMS





CDS Measure ID(s) HEN2-SSI-3e






AHA/HRET HEN 2.0


31

ABCDEF Bundle Compliance

VAE: HEN Process Measure

Percentage of patients who underwent the ABCDEF bundle assessment


Numerator Number of patients on a ventilator who were assessed with the ABCDEF Bundle (all individual elements)

Denominator Total number of patients on a ventilator




Available from the ICU Delirium and Cognitive Impairment Study Group - Vanderbilt University





CDS Measure ID(s) HEN2-VAE-3a

AHA/HRET HEN 1 EOM-VAE-131 (“F" has been added to the bundle since HEN 1.0)

NQF Not endorsed

Additional references: The Partnership for Patients has gathered many resources for ventilator-associated event (VAE) prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-ventilator-associatedpneumonia/toolventilator-associatedpneumoniavap.html

http://www.icudelirium.org/medicalprofessionals.html

http://partnershipforpatients.cms.gov/p4p_resources/tsp-ventilator-associatedpneumonia/toolventilator-associatedpneumoniavap.html


AHA/HRET HEN 2.0


32

Spontaneous Awakening Trial Rate

VAE: CMS HEN Process Measure

Percentage of eligible patients who receive spontaneous awakening trial


Numerator Number of patients with spontaneous awakening trial (SAT) performed

Denominator Number of patients eligible for spontaneous awakening trial (SAT)









CDS Measure ID(s) HEN2-VAE-3b

AHA/HRET HEN 1 EOM-VAE-134





AHA/HRET HEN 2.0


33

Spontaneous Breathing Trial Rate

VAE: HEN Process Measure

Percentage of eligible patients who receive spontaneous breathing trial


Numerator Number of patients with spontaneous breathing trial performed

Denominator Number of patients eligible for spontaneous breathing trial









CDS Measure ID(s) HEN2-VAE-3c

AHA/HRET HEN 1 EOM-VAE-135





AHA/HRET HEN 2.0


34

Venous Thromboembolism Prophylaxis

VTE: HEN Process Measure - NQF 371 (VTE-1)

Percentage of patients who got treatment to prevent blood clots on the day of or day after hospital admission or surgery


Numerator

Patients who received venous thromboembolism (VTE)

prophylaxis (or have documentation for why no VTE prophylaxis

was given):

Surgery inpatients – the day of or the day after surgery (for

surgeries that start the day of or the day after hospital

admission), OR

All other inpatients – the day of or day after hospital admission





Available from CMS





CDS Measure ID(s) HEN2-VTE-2a

AHA/HRET HEN 1 EOM-VTE-99

Additional References: The Partnership for Patients has also gathered many resources for venous thromboembolism (VTE) prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-venusthromboembolism/toolvenousthromboembolismvte.html


http://partnershipforpatients.cms.gov/p4p_resources/tsp-venusthromboembolism/toolvenousthromboembolismvte.html


AHA/HRET HEN 2.0


35

Surgery Patients who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours

Prior to Surgery to 24 Hours after Surgery

VTE: HEN Process Measure – NQF 218 (SCIP-VTE-2)

Percentage of surgery patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery


Numerator Surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to anesthesia start time to 24 hours after anesthesia end time.

Denominator All selected surgery patients




Available from CMS





CDS Measure ID(s) HEN2-VTE-2b


Additional References: The Partnership for Patients has also gathered many resources for VTE prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-venusthromboembolism/toolvenousthromboembolismvte.html




AHA/HRET HEN 2.0


36

Venous Thromboembolism Warfarin Therapy Discharge Instructions

VTE: HEN Process Measure – NQF 0375 (VTE-5)

Percentage of patients diagnosed with confirmed VTE who are discharged (to home, home care, home hospice care, or court/law enforcement) on warfarin with written discharge instructions


Numerator Patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin that addressed all CMS-designated issues





Available from CMS





CDS Measure ID(s) HEN2-VTE-2c


Additional References: The Partnership for Patients has also gathered many resources for VTE prevention and measurement. These resources are catalogued online at the following link: http://partnershipforpatients.cms.gov/p4p_resources/tsp-venusthromboembolism/toolvenousthromboembolismvte.html


