Prospective  Data  Elements      

Measure  Name     Measure  Description/Examples   Data  Plan/  Action  

Required  Publicly  Reported  Measures  

Diagnosed  Diabetes,  age  adjusted  

CDC  annual  measure  of  diabetes  prevalence.   Publicly  reported  data.  No  action  required  NCHA  will  supply  to  Dartmouth  and  notify  hospitals  

CMS  Readmit  by  Condition:  HA,  HF,  PN,  COPD,  

STK  

CMS  readmissions  of  Medicare  patients  by  condition  including:  heart  attack,  heart  failure,  pneumonia,  chronic  obstructive  

pulmonary  disease  and  stroke  CMS  Readmit  by  

Procedure:  CABG,  Hip/Knee  

CMS  readmissions  of  Medicare  patients  by  procedure  including:  coronary  artery  bypass  grafting,  lower  extremity  joint  replacement  

CMS  Readmit  Hospital  Wide  

CMS  hospital  wide  readmissions  of  Medicare  patients  

HCAHPS  9  dimensions  of  

patient  experience  of  

care  

CMS  Hospital  Consumer  Assessment  of  Healthcare  Providers  and  Systems  for  all  

adult  inpatients  excluding  psychiatric  patients  –  9  dimensions  include  communication  with  

doctors,  communication  with  nurses,  responsiveness  of  hospital  staff,  pain  management,  communication  about  

medicines,  discharge  information,  cleanliness  of  the  hospital  environment,  quietness  of  the  hospital  environment,  and  transition  of  care  

HCAHPS  Global  Measures:  Definitely  

Recommend,  Rate  9  or  10  Overall  

CMS  Hospital  Consumer  Assessment  of  Healthcare  Providers  and  Systems  for  all  adult  inpatients  excluding  psychiatric  

patients,  overall  ratings  of  care  

 

     

 

Measure  Name     Measure  Description/Examples   Data  Plan/  Action  

Required  HCAHPS  

Summary  Star  Rating  

CMS  summary  star-­‐rating  from  Hospital  Consumer  Assessment  of  Healthcare  

Providers  and  Systems  for  all  adult  inpatients  excluding  psychiatric  patients  

Medicare  Spending  per  Beneficiary  

CMS  measure  evaluates  hospitals’  efficiency,  as  reflected  by  Medicare  payments  made  during  an  MSPB  episode,  relative  to  the  

efficiency  of  the  median  hospital  Claims-­‐based  measures  

ED  utilization  data  

Emergency  department  visits,  all  causes   Covered  by  a  data  use  agreement.  NCHA  will  submit  to  Dartmouth  

ED  utilization  for  mental  health  

Emergency  department  visits  for  mental  health    

Admissions  by  diagnosis  group  

Number  of  inpatient  admissions  by  diagnosis  group,  including  mental  health  diagnoses  

Length  of  Stay   Average  length  of  stay  and  expected  length  of  stay  overall  and  by  diagnosis  groups  

Agency  on  Healthcare  

Research  and  Quality  (AHRQ),  

22  Patient  Safety  

Indicators  (PSI)  

PSI  02  Death  Rate  in  Low-­‐Mortality  Diagnosis  Related  Groups  (DRGs)  

PSI  03  Pressure  Ulcer  Rate  PSI  04  Death  Rate  among  Surgical  Inpatients  

with  Serious  Treatable  Conditions  PSI  05  Retained  Surgical  Item  or  Unretrieved  

Device  Fragment  Count  PSI  06  Iatrogenic  Pneumothorax  Rate  

PSI  07  Central  Venous  Catheter-­‐Related  Blood  Stream  Infection  Rate  

PSI  08  Postoperative  Hip  Fracture  Rate  

 

     

 

Measure  Name     Measure  Description/Examples   Data  Plan/  Action  

Required  PSI  09  Perioperative  Hemorrhage  or  

Hematoma  Rate  PSI  10  Postoperative  Physiologic  and  

Metabolic  Derangement  Rate  PSI  11  Postoperative  Respiratory  Failure  Rate  PSI  12  Perioperative  Pulmonary  Embolism  or  

Deep  Vein  Thrombosis  Rate  PSI  13  Postoperative  Sepsis  Rate  

PSI  14  Postoperative  Wound  Dehiscence  Rate  PSI  15  Accidental  Puncture  or  Laceration  Rate  

PSI  16  Transfusion  Reaction  Count  PSI  17  Birth  Trauma  Rate  –  Injury  to  Neonate  

PSI  18  Obstetric  Trauma  Rate  –  Vaginal  Delivery  With  Instrument  

PSI  19  Obstetric  Trauma  Rate-­‐Vaginal  Delivery  Without  Instrument  

PSI  21  Retained  Surgical  Item  or  Unretrieved  Device  Fragment  Rate  

PSI  22  Iatrogenic  Pneumothorax  Rate  PSI  23  Central  Venous  Catheter-­‐Related  Blood  

Stream  Infection  Rate  PSI  24  Postoperative  Wound  Dehiscence  Rate  PSI  25  Accidental  Puncture  or  Laceration  Rate  

PSI  26  Transfusion  Reaction  Rate  PSI  27  Perioperative  Hemorrhage  or  

Hematoma  Rate  PSI  90  Patient  Safety  for  Selected  Indicators  

RAMI     Risk-­‐Adjusted  Mortality  Index  (RAMI):    risk  adjusted  mortality  probability    

 

     

 

Measure  Name     Measure  Description/Examples   Data  Plan/  Action  

Required  ECRI   Expected  Complication  Rate  Index  (ECRI)  risk  

adjusted  probability  of  complications  Readmissions  measures  

All-­‐cause,  all-­‐payer  30  day  readmission  rate,  including  Readmission  for  any  reason;  

Readmission  for  same  clinical  classification;  Readmit  patient  migration;  Top  10  CCS  for  

readmissions.    Hospital-­‐Specific  Measures  

 

Participation  in  CMS  Innovation  projects     Quality  and  performance  metrics  from  

strategic  plan  Hospital  will  select  which  

measures  to  submit  and  send  directly  to  Dartmouth  

  Physician-­‐specific  performance  metrics  

  Information  to  drive  affinity  groups