Diabetes. RF07. Chronic cerebrovascular disease. RF08. Chronic renal disease. RF11. COPD Diabetes (RF05) AND Obesity (RF10) Pneumonia Efficiency Measures …
New Measures for 2008 Leapfrog Survey
Efficiency Measures for CABG and PCI
Hospitals will be asked to report on the efficiency of care provided to
CABG and PCI patients The proposed measures and example risk factors are
outlined below
The case criteria for the CABG efficiency counts will be the same criteria
as the volume counting criteria The case criteria for PCI efficiency
counts will have some additional exclusion criteria as to eliminate
outpatient PCIs from ALOS, readmissions, and risk-factor case counts
Hospitals must have at least 30 cases for a condition CABG or PCI that
are treated and not transferred out in order to report on efficiency of
care Hospitals that do not meet the 30 cases for a condition will be able
to indicate that in the survey
The efficiency measures and the pro forma risk factors, both which are
subject to revision are as follows:
| |
|Coronary Artery Bypass Graft CABG - Efficiency Measures |
| |
|See general specifications for computing and reporting efficiency |
|measures, as
well as inclusion/exclusion criteria particular to this |
|procedure |
|Total number of discharges with a CABG procedure at this | |
|hospital location |_______ |
|for the volume reporting period meeting the | |
|inclusion/exclusion criteria for measuring efficiency | |
|ie overall hospital volume count for the procedure | |
| | |
|All remaining questions pertain to these cases only | |
|Number of discharges reported in question 1 which were | |
|followed by a readmission to this same hospital location, |_______ |
|regardless of condition/cause of re-admission, within 15 | |
|days following discharge | |
|Average length of stay for discharges reported in question| |
|1 |_______ |
|Report average days/discharge with two decimal place |eg, 765 |
|precision
| |
|Number of discharges reported in question 1 which had the selected risk |
|factor present, respectively: enter 0 if no discharges had that risk |
|factor present |
| | | |Number of |
| |Risk |Description, brief - see detailed |Discharges |
| |Factor |specifications |in Q26 with |
| | | |Risk Factor Present|
| | | | |
| |RF01 |Age 55 |_______ |
| | | | |
| |RF02 |Male |_______ |
| | | | |
| |RF05 |Diabetes |_______ |
| | | | |
| |RF07 |Chronic cerebrovascular disease |_______
|
| | | | |
| |RF08 |Chronic renal disease |_______ |
| | | | |
| |RF11 |COPD |_______ |
| | | | |
| |RF12 |Cardiomyopathy |_______ |
| | | | |
| |RF13 |Chronic cardiac conditions |_______ |
| | | | |
| |RF15 |Atherosclerosis and lipid disorders |_______ |
| | | | |
| |RF16 |PCI |_______ |
| | | | |
| |RF18 |Musculoskeletal conditions |_______ |
| | | | |
| |RF19 |AMI
|_______ |
| | | | |
| |RF20 |CAD without prior CABG |_______ |
| | | | |
| |RF21 |CAD with prior CABG |_______ |
| |
|Percutaneous Coronary Intervention PCI - Efficiency Measures |
| |
|See general specifications for computing and reporting efficiency |
|measures, as well as inclusion/exclusion criteria particular to this |
|procedure |
|Total number of discharges with a PCI procedure at this | |
|hospital location |_______ |
|for the volume reporting period meeting the | |
|inclusion/exclusion criteria for measuring efficiency | |
|ie overall hospital volume count for the procedure | |
|
| |
|All remaining questions pertain to these cases only | |
|Number of discharges reported in question 1 which were | |
|followed by a readmission to this same hospital location, |_______ |
|regardless of condition/cause of re-admission, within 15 | |
|days following discharge | |
|Average length of stay for discharges reported in question| |
|1 |_______ |
|Report average days/discharge with two decimal place |eg, 765 |
|precision | |
|Number of discharges reported in question 1 which had the selected risk |
|factor present, respectively: enter 0 if no discharges had that risk |
|factor present |
| | | |Number of |
| |Risk |Description, brief - see detailed |Discharges |
| |Factor |specifications |in Q21 with |
| |
| |Risk Factor Present|
| | | | |
| |RF01 |Age 55 |_______ |
| | | | |
| |RF02 |Male |_______ |
| | | | |
| |RF03 |Site of infarction: anterior or |_______ |
| | |anteriolateral | |
| | | | |
| |RF04 |Site of infarction: subendocardial |_______ |
| | | | |
| |RF05 |Diabetes |_______ |
| | | | |
| |RF06 |Cancer |_______ |
| | | | |
| |RF07 |Chronic cerebrovascular disease
|_______ |
| | | | |
| |RF08 |Chronic renal disease |_______ |
| | | | |
| |RF09 |Chronic liver disease |_______ |
| | | | |
| |RF10 |Obesity |_______ |
| |RF11 | | |
| | |COPD definition differs from RF36 | |
| | | |_______ |
| | | | |
| |RF12 |Cardiomyopathy |_______ |
| | | | |
| |RF13 |Chronic cardiac conditions |_______ |
| | | | |
| |RF14 |History of PTCA |_______ |
| | |
| |
| |RF15 |Atherosclerosis and lipid disorders |_______ |
| | | | |
| |RF17 |CABG |_______ |
| | | | |
| |RF18 |Musculoskeletal conditions |_______ |
| | | | |
| |RF19 |AMI |_______ |
Pneumonia and AMI Quality of Care Process Measures
Joint Commission measures, endorsed by the National Quality Forum, which
measure quality-of-care and safety processes, will be used to assess the
adoption of safety practices for pneumonia and AMI patients
Hospitals that report to The Joint Commission TJC will be able to use
their TJC submitted data to complete this section of the survey For
hospitals that do not report to TJC, measure specifications that mirror the
TJC measures will be provided
Hospitals must have at least 30 cases for a condition Pneumonia or AMI
that are treated and not
transferred out in order to report on quality of
care Hospitals that do not meet the 30 cases for a condition will be able
to indicate that in the survey
The measures are as follows:
| |
|Acute Myocardial Infarctions AMI - Process Measures of Quality |
| |
|Indicate your hospitals adherence to nationally endorsed |
|procedure-specific process measures of quality specific to this |
|procedure, if measured see Process Measures link on survey home page |
|Instructions |
|For each of the seven guidelines, indicate: |
|whether your hospital has performed a medical record audit on all cases |
|or a sufficient sample of them for AMI patients for the 12-month period|
|ending { December 31, 2007 | June 30, 2007 } and measured adherence to |
|the Leapfrog expert panel-endorsed clinical process guideline for this |
|procedure |
|If no, skip b and c for this
procedure |
|the number of cases measured against the guideline, either all cases or |
|the sample size, for this procedure ie, number of cases audited and |
|meeting the criteria for inclusion in the denominator of the measure |
|The number of cases in b that adhere to the Leapfrog expert |
|panel-endorsed clinical process guideline for this procedure numerator|
| |
| |
| Responses can and should be based on the same data reported to Joint |
|Commission for National Hospital Quality Measures where those data have |
|been reported and accepted by the Joint Commission Otherwise, hospitals |
|can measure and report results as described here and in the Process |
|Measures specifications see link on home page |
| |a |b | c |
|Guideline |Measured? | Cases | Cases |
| |if No, |Measured |Adhere |
| |skip
b and |denominator|numerator |
| |c | | |
| |Aspirin at arrival AMI-1 |Yes | | |
| | |No |______ |______ |
| |Aspirin at discharge |Yes | | |
| |AMI-2 |No |______ |______ |
| |ACEI for LVSD AMI-3 |Yes | | |
| | |No |______ |______ |
| |Smoking cessation |Yes | | |
| |counseling |No |______ |______ |
| |AMI-4 | | | |
| |Beta blocker at discharge |Yes | | |
| |AMI-5 |No |______ |______ |
| |Beta blocker at arrival |Yes | | |
| |AMI-6 |No |______ |______ |
| |
|Pneumonia - Process Measures of Quality
|
| |
|Indicate your hospitals adherence to nationally endorsed |
|procedure-specific process measures of quality specific to this |
|procedure, if measured see Process Measures link on survey home page |
|Instructions |
|For each of the seven guidelines, indicate: |
|whether your hospital has performed a medical record audit on all cases |
|or a sufficient sample of them for pneumonia patients for the 12-month |
|period ending { December 31, 2007 | June 30, 2007 } and measured |
|adherence to the Leapfrog expert panel-endorsed clinical process |
|guideline for this procedure |
|If no, skip b and c for this procedure |
|the number of cases measured against the guideline, either all cases or |
|the sample size, for this procedure ie, number of cases audited and |
|meeting the criteria for inclusion in the denominator of the measure |
|The number of cases in b that adhere to the
Leapfrog expert |
|panel-endorsed clinical process guideline for this procedure numerator|
| |
| |
| Responses can and should be based on the same data reported to Joint |
|Commission for National Hospital Quality Measures where those data have |
|been reported and accepted by the Joint Commission Otherwise, hospitals |
|can measure and report results as described here and in the Process |
|Measures specifications see link on home page |
| |a |b | c |
|Guideline |Measured? | Cases | Cases |
| |if No, |Measured |Adhere |
| |skip b and |denominator|numerator |
| |c | | |
| |Oxygenation assessment |Yes | | |
| |PN-1 |No |______ |______ |
| |Pneumococcal immunization |Yes |
| |
| |PN-2 |No |______ |______ |
| |Blood cultures prior to |Yes | | |
| |antibiotic |No |______ |______ |
| |PN-3b | | | |
| |Smoking cessation |Yes | | |
| |counseling |No |______ |______ |
| |PN-4 | | | |
| |Antibiotics within 4 hours |Yes | | |
| |of ER arrival PN-5b |No |______ |______ |
| |Influenza immunization |Yes | | |
| |PN-7 |No |______ |______ |
Efficiency Measures for Pneumonia and AMI
Hospitals will be asked to report on the efficiency of care provided to
pneumonia and AMI patients The proposed measures and example risk
factors are outlined below
The case criteria for the efficiency measures will match the case criteria
used for the pneumonia and AMI quality-of-care process
measures
Hospitals must have at least 30 cases for a condition Pneumonia or AMI
that are treated and not transferred out in order to report on efficiency
of care Hospitals that do not meet the 30 cases for a condition will be
able to indicate that in the survey
The efficiency measures and the pro forma risk factors, both which are
subject to revision are as follows:
| |
|Acute Myocardial Infarctions AMI - Efficiency Measures |
| |
|See general specifications for computing and reporting efficiency |
|measures, as well as inclusion/exclusion criteria particular to this |
|procedure |
|Total number of discharges with principal diagnosis of AMI| |
|at this hospital location for the volume reporting period |_______ |
|meeting the inclusion/exclusion criteria for measuring | |
|efficiency ie overall hospital volume count for the | |
|condition |
|
| | |
|All remaining questions pertain to these cases only | |
|Number of discharges reported in question 1 which were | |
|followed by a readmission to this same hospital location, |_______ |
|regardless of condition/cause of re-admission, within 15 | |
|days following discharge | |
|Average length of stay for discharges reported in question| |
|1 |_______ |
|Report average days/discharge with two decimal place |eg, 765 |
|precision | |
|Number of discharges reported in question 1 which had the selected risk |
|factor present, respectively: enter 0 if no discharges had that risk |
|factor present |
| | | |Number of |
| |Risk |Description, brief - see detailed |Discharges |
| |Factor |specifications |in Q1
with |
| | | |Risk Factor Present|
| | | | |
| |RF01 |Age 55 |_______ |
| | | | |
| |RF02 |Male |_______ |
| | | | |
| |RF03 |Site of infarction: anterior or |_______ |
| | |anteriolateral | |
| | | | |
| |RF04 |Site of infarction: subendocardial |_______ |
| | | | |
| |RF05 |Diabetes |_______ |
| | | | |
| |RF06 |Cancer |_______ |
| | | | |
| |RF07 |Chronic
cerebrovascular disease |_______ |
| | | | |
| |RF08 |Chronic renal disease |_______ |
| | | | |
| |RF09 |Chronic liver disease |_______ |
| | | | |
| |RF10 |Obesity |_______ |
| | | | |
| |RF11 |COPD definition differs from RF36 |_______ |
| | | | |
| |RF12 |Cardiomyopathy |_______ |
| | | | |
| |RF13 |Chronic cardiac conditions |_______ |
| | | | |
| |RF15 |Atherosclerosis and lipid disorders |_______ |
| | | |
|
| |RF16 |PCI |_______ |
| | | | |
| |RF17 |CABG |_______ |
| | | | |
| |RF21 |CAD with prior CABG |_______ |
| | | | |
| |RF22 |Diabetes RF05 AND Obesity RF10 |_______ |
| |
|Pneumonia - Efficiency Measures |
| |
|See general specifications for computing and reporting efficiency |
|measures, as well as inclusion/exclusion criteria particular to this |
|procedure |
|Total number of discharges with principal diagnosis of | |
|pneumonia at this hospital location for the volume |_______ |
|reporting period meeting the inclusion/exclusion
criteria | |
|for measuring efficiency ie overall hospital volume | |
|count for the condition | |
| | |
|All remaining questions pertain to these cases only | |
|Number of discharges reported in question 1 which were | |
|followed by a readmission to this same hospital location, |_______ |
|regardless of condition/cause of re-admission, within 15 | |
|days following discharge | |
|Average length of stay for discharges reported in question| |
|1 |_______ |
|Report average days/discharge with two decimal place |eg, 765 |
|precision | |
|Number of discharges reported in question 1 which had the selected risk |
|factor present, respectively: enter 0 if no discharges had that risk |
|factor present |
| | |
|Number of |
| |Risk |Description, brief - see detailed |Discharges |
| |Factor |specifications |in Q1 with |
| | | |Risk Factor Present|
| | | | |
| |RF01 |Age 55 |_______ |
| | | | |
| |RF02 |Male |_______ |
| | | | |
| |RF30 |Any cancer except basal or |_______ |
| | |squamous-cell skin cancer | |
| | | | |
| |RF31 |Cirrhosis or chronic hepatitis |_______ |
| | | | |
| |RF32 |Stroke or transient ischemic attack |_______ |
| | | | |
| |RF33
|Congestive heart failure |_______ |
| | | | |
| |RF34 |Kidney disease |_______ |
| | | | |
| |RF35 |Suspected or documented HIV |_______ |
| | | | |
| |RF36 |COPD definition differs from RF11 |_______ |
| | |ALREADY IDENTIFIED AS NOT FEASIBLE WITH| |
| |RF37 |ADMINISTRATIVE DATA |_______ |
| | |Inability to take oral medications | |
| | |ALREADY IDENTIFIED AS NOT FEASIBLE WITH| |
| |RF38 |ADMINISTRATIVE DATA |_______ |
| | |Temperature below 35C 95F or above | |
| | |40C 104F | |
| | |ALREADY IDENTIFIED AS NOT FEASIBLE WITH| |
| |RF39 |ADMINISTRATIVE DATA |_______
|
| | |Altered mental status | |
| | | | |
| |RF41 |Sodium below 130 mEq/L |_______ |
| | | | |
| |RF42 |Hematocrit less than 30 |_______ |
| | | | |
| |RF43 |Pleural effusion |_______ |
| | | | |
| |RF44 |Septicemia |_______ |
| | | | |
| |RF45 |Respiratory failure |_______ |
CMS HACs - Pressure Ulcers and Hospital-Acquired Injuries
Two hospital-acquired conditions HACs that CMS will no longer reimburse
hospitals for will be added to the 2008 Survey The measurement
specifications for calculating rates for these two conditions - pressure
ulcers and hospital-acquired injuries - are as follows:
|CMS HAC-1: Rate of
Pressure Ulcers |
|Source: The Leapfrog Group |
|Numerator: Number of occurrences with an ICD-9 code in a secondary |
|diagnosis field in the ranges: 800-829, 830-839, 850-854, 925-929, |
|940-949, 991-994 |
|Denominator: Total inpatient days |
|Exclusions: |
|Present on admission POA indicator for the condition indicates |
|that the condition was present at admission |
|Patients who are less than 18 years of age |
|CMS HAC-2: Rate of Hospital-Acquired Injuries |
|Source: The Leapfrog Group |
|Numerator: Number of occurrences with an ICD-9 code in a secondary |
|diagnosis field of 70700, 70701, 70702, 70703, 70704, 70705, |
|70706, 70707, 70709 |
|Denominator: Total inpatient days |
|Exclusions: |
|Present on admission
POA indicator for the condition indicates |
|that the condition was present at admission |
|Patients who are less than 18 years of age |
Source:decaade.org
