Hospital Quality Information

Starter Set of 10 Hospital Quality Measures

CMS will publicly report on the starter set of 10 hospital quality measures for those hospitals participating in the CMS Hospital 3-State Pilot, the national voluntary reporting effort, and the special partnership with the Connecticut Department of Public Health.

The starter set of 10 hospital quality measures has gone through years of extensive testing for validity and reliability by CMS and its Quality Improvement Organizations, The Joint Commission and researchers. The hospital quality measures are also endorsed by the National Quality Forum, a national standards setting entity.

Condition: Acute Myocardial Infarction (AMI) / Heart Attack

   1. Aspirin at arrival
   2. Aspirin at discharge
   3. Beta-Blocker at arrival
   4. Beta-Blocker at discharge
   5. ACE Inhibitor for left ventricular systolic dysfunction

Condition: Heart Failure

   6. Left ventricular function assessment
   7. ACE inhibitor for left ventricular systolic dysfunction

Condition: Pneumonia

   8. Initial antibiotic timing
   9. Pneumococcal vaccination
  10. Oxygenation assessment

The starter set of 10 hospital quality measures was chosen because they are related to three serious medical conditions that are common among people with Medicare and because they reflect widely accepted standards of practice. They are also feasible for hospitals to collect and submit for public reporting today. Both CMS and The Joint Commission provide their own processes to submit data and use data edit procedures to check data for completeness and accuracy. In addition, the quality measures are well understood by providers and stakeholders and can be validated by CMS with existing resources through its QIO program.

Expanded Set of 34 Premier Hospital Quality Measures (Quality Incentive Demonstration Set)

The Premier Hospital Quality Incentive Demonstration includes an expanded set of 24 measures in addition to the starter set of 10 quality measures used in the other Hospital Quality Initiative components. The additional measures include two categories of surgical procedures and are indicated by an asterisk in the chart below.

Condition: Acute Myocardial Infarction (AMI)

   1. Aspirin at arrival
   2. Aspirin prescribed at discharge
   3. ACEI for LVSD
   4. Smoking cessation advice/counseling*
   5. Beta blocker prescribed at discharge
   6. Beta blocker at arrival
   7. Thrombolytic received within 30 minutes of hospital arrival*
   8. Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival*
   9. Inpatient mortality rate*

Condition: Coronary Artery Bypass Graft (CABG)

  10. Aspirin prescribed at discharge*
  11. CABG using internal mammary artery*
  12. Prophylactic antibiotic received within 1 hour prior to surgical incision*
  13. Prophylactic antibiotic selection for surgical patients*
  14. Prophylactic antibiotics discontinued within 24 hours after surgery end time*
  15. Inpatient mortality rate*
  16. Post-operative hemorrhage or hematoma*
  17. Post-operative physiologic and metabolic derangement*

Condition: Heart Failure (HF)

  18. Left ventricular function (LVF) assessment
  19. Detailed discharge instructions*
  20. ACEI for LVSD
  21. Smoking cessation advice/counseling*

Condition: Community Acquired Pneumonia (CAP)

  22. Oxygenation assessment
  23. Initial antibiotic consistent with current recommendations*
  24. Blood culture collected prior to first antibiotic administration*
  25. Influenza screening/vaccination*
  26. Pneumococcal screening/vaccination
  27. Initial antibiotic timing
  28. Smoking cessation advice/counseling*

Condition: Hip and Knee Replacement

  29. Prophylactic antibiotic received within 1 hour prior to surgical incision*
  30. Prophylactic antibiotic selection for surgical patients*
  31. Prophylactic antibiotics discontinued within 24 hours after surgery end time*
  32. Post-operative hemorrhage or hematoma*
  33. Post-operative physiologic and metabolic derangement*
  34. Readmissions 30 days post discharge*

* Measures added to the 10-measure starter set

The Premier measures that were added to the National Quality Forum (NQF) starter set have been well tested by Premier and/or others in hospital settings, and have been deemed feasible to be collected and reported now. These measures include many that are endorsed by the NQF and will test measures for possible future reporting on hospital quality.

HCAHPS- Patient Perspectives on Care Measures

The Agency for Healthcare Research and Quality (AHRQ) is working with CMS to create a standard format for collecting and reporting patient perspectives on care data that can be used to compare experiences at different hospitals. The HCAHPS draft instrument was tested by hospitals participating in the CMS Hospital 3-State Pilot and the special partnership with the Connecticut Department of Public Health.

The process for HCAHPS reflects a rigorous process of scientific research, consumer and field-testing, and multiple opportunities for public input. On December 5, a Federal Register notice was published soliciting comments on the revised HCAHPS instrument and implementation strategy. Using public input received and input from additional testing, CMS and AHRQ are revising the HCAHPS instrument and implementation strategy. Once the final instrument is available, hospitals participating in the National Voluntary Hospital Reporting Initiative will begin to use it.

Creation of Robust Prioritized Measure Set

During the initial public reporting activities, CMS will learn what works for patients and their health-care providers, and create momentum through partnerships and collaborations. In Spring 2004, we engaged the public in a structured dialogue to help identify a more compete set of hospital quality measures. Through a number of town hall-style meetings and formal/informal input processes, CMS identified a robust, prioritized, and uniform set of hospital quality measures for national public reporting. Our ultimate goal is for this set of measures to be reported by all hospitals (led by those in the national voluntary reporting effort), and accepted by all purchasers, oversight and accrediting entities, payers and providers. We anticipate that this process will identify some measures ready for immediate reporting, some needing refinement or final testing, and some needing extensive developmental work. CMS will undertake such necessary follow-up activities, and will work with the hospitals and our partners to resolve data collection and transmission issues. All measures will be submitted to the NQF for consideration in their consensus process.