1. Option Year 1 Metrics January 14, 2014 100 E. Grand Ave., Ste. 360 Des Moines, IA 50309-1800 Office: 515.283.9330 Fax: 515.698.5130 www.ihconline.org

2. Overview Goal: To decrease reporting burden for hospitals Begins with January 2014 data Color coding IPOP

3. Program is being updated for OY1 data collection. Changes will be made available later this quarter. Each hospital must report separately Metric counts Current custom metrics will be evaluated individually for decision on 2014 data collection New customs will be assessed individually for relevancy NHNS metrics will have an option for self-reporting

4. Readmissions Process NumeratorDenominator Observed Interactions Where Teach Back is Used by Nurses per the Number of Observations Number of observations of nurses where teach-back is used to assess understandingNumber of observations of nurse teaching Discharged Patients with Community Providers Included in Post-Discharge Needs Evaluation Number of patient discharges included in the denominator population that are compliant with community providers being included in the post-discharge needs evaluation Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed patients Discharged Patients with Follow-up Appointment Scheduled Before Discharge Number of patient discharges included in the denominator population with follow-up appointment scheduled before discharge in accordance with risk assessment Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed patients Discharged Patients Where Critical Information is Shared Appropriately Number of patient discharges included in the denominator population where critical information is transmitted to the next site of care (e.g. office, LTC, HH) Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed patients Outcome NumeratorDenominator Percent of All-Cause, 30-Day Readmissions Number of patient discharges in the denominator population that meet criteria for inclusion as a readmission all-cause, 30-day methodology Number of discharges for Acute Care patients reported in the month of discharge date

5. CAUTI CAUTI (Catheter-Associated Urinary Tract Infection) Process NumeratorDenominator Unnecessary Urinary Catheters (Urinary catheters not meeting criteria for appropriate insertion) Number of patients in the denominator population with new indwelling urinary catheters inserted without appropriate indication documented at the time of insertion Number of patients with new indwelling urinary catheter insertions for Acute Care, Skilled Nursing Care and Swing Bed patients Efficiency NumeratorDenominator Rate of Urinary Catheter Utilization per Patient Day Number of patient days in the denominator population with urinary catheter in placeNumber of patient days for Acute Care, Skilled Nursing Care and Swing Bed patients Emergency Department Catheter Utilization Number of indwelling urinary catheter placements in the Emergency DepartmentNumber of patients admitted to Acute Care, Skillled Nursing Care or Swing Bed status through the Emergency Department Outcome NumeratorDenominator Hospital-Acquired, Catheter-Associated UTI Rate per Catheter Day Number of hospital-acquired UTIs for patients in the denominator population per NHSN guidelines Number of urinary catheter days for Acute Care, Skilled Nursing Care and Swing Bed patients OR for NHSN-defined units

6. CLABSI CLABSI (Central Line-Associated Bloodstream Infection) Process NumeratorDenominator Inpatients with Full Bundle PICC Line and/or Central Line Catheter Insertion Compliance per the Number of patients with PICC Line and/or Central Lines Inserted Number of patients in the denominator population with full PICC line and/or central line catheter insertion bundle compliance Number of PICC line and/or central line insertions for Acute Care, Skilled Nursing Care and Swing Bed patients Inpatients with Full Bundle PICC Line and/or Central Line Catheter Maintenance Compliance per the Number of Central Line Catheter Days Number of patients in the denominator population with full PICC line and/or central line maintenance bundle compliance Number of PICC line and/or central line insertions for Acute Care, Skilled Nursing Care and Swing Bed patients Outcome NumeratorDenominator Hospital-Acquired, Central Line-Associated Bloodstream Infection Rate per Catheter Day Number of hospital-acquired, central line-associated bloodstream infections for the patients in the denominator population per NHSN guidelines Number of central line catheter days for Acute Care, Skilled Nursing Care and Swing Bed patients

7. SSI SSI (Surgical Site Infection) Process NumeratorDenominator Acute Surgical Inpatients with Full SCIP Compliance per the Number of SCIP Surgical Episodes Number of surgical inpatients in the denominator population with full surgical infection prevention bundle compliance for SCIP 1, 2, 3, 9 (CMS IQR) Number of SCIP 1, 2, 3, 9 inpatient surgical episodes Outcome – SSI – NHSN Reporting Hospitals – select 4 surgery types from the following: NumeratorDenominator Colon Surgical Site Infection Rate per Inpatient Colon Surgical Episodes Number of hospital-acquired colon surgical site infections in the denominator population per NHSN guidelines Number of NHSN-defined colon surgical episodes Abdominal Hysterectomy Surgical Site Infection Rate per Inpatient Abdominal Hysterectomy Surgical Episode Number of hospital-acquired abdominal hysterectomy surgical site infections in the denominator population per NHSN guidelines Number of NHSN-defined abdominal hysterectomy surgical episodes Hip Replacement Surgical Site Infection Rate per Inpatient Hip Replacement Surgical Episodes Number of hospital-acquired hip replacement surgical site infections in the denominator population per NHSN guidelines Number of NHSN-defined hip replacement surgical episodes Knee Replacement Surgical Site Infection Rate per Inpatient Knee Replacement Surgical Episodes Number of hospital-acquired knee replacement surgical site infections in the denominator population per NHSN guidelines Number of NHSN-defined knee replacement surgical episodes Cardiac Surgery Surgical Site Infection Rate per Inpatient Cardiac Surgical Episodes Number of hospital-acquired cardiac surgery surgical site infections in the denominator population per NHSN guidelines Number of NHSN-defined cardiac procedure surgical episodes

8. SSI (cont) Outcome - Non-NHSN Reporting Hospitals NumeratorDenominator Colon Surgical Site Infection Rate per Inpatient Colon Surgical Episodes Number of hospital-acquired colon surgical site infections in the denominator population per NHSN guidelines Number of NHSN-defined colon surgical episodes Abdominal Hysterectomy Surgical Site Infection Rate per Inpatient Abdominal Hysterectomy Surgical Episode Number of hospital-acquired abdominal hysterectomy surgical site infections in the denominator population per NHSN guidelines Number of NHSN-defined abdominal hysterectomy surgical episodes Hip Replacement Surgical Site Infection Rate per Inpatient Hip Replacement Surgical Episodes Number of hospital-acquired hip replacement surgical site infections in the denominator population per NHSN guidelines Number of NHSN-defined hip replacement surgical episodes Knee Replacement Surgical Site Infection Rate per Inpatient Knee Replacement Surgical Episodes Number of hospital-acquired knee replacement surgical site infections in the denominator population per NHSN guidelines Number of NHSN-defined knee replacement surgical episodes

9. VAE VAE (Ventilator-Associated Event) Process NumeratorDenominator Percent of Ventilator Patients with Full Bundle Compliance Number of ICU patients in the denominator population on mechanical ventilation with full ventilator-associated prevention bundle compliance Number of ICU patients on mechanical ventilation on day of week of sample Outcome NumeratorDenominator VAC - All Units* Number of events that meet VAC criteriaNumber of ventilator days IVAC - All Units* Number of events that meet IVAC criteriaNumber of ventilator days Possible/Probable VAP Rate - All Units* Number of events that meet possible/probable criteriaNumber of ventilator days *Hierarchy of definitions If a patient meets criteria for VAC and IVAC, report as IVAC If a patient meets criteria for VAC, IVAC and Possible VAP; report as Possible/Probable VAP If a patient meets criteria for VAC, IVAC and Probable VAP; report as Possible/Probable VAP If a patient meets criteria for VAC, IVAC, Possible and Probable VAP; report as Probable VAP

10. Adverse Drug Events ADE (Adverse Drug Events) Process NumeratorDenominator Documented Blood Glucose Values Less Than 50 per Number of Measurements Number of lab measurements with documented blood glucose <50Number of patient blood glucose lab measurements Documented INRs Greater Than 5 for Patients on Warfarin per Number of Measurements Number of lab measurements with documented INR >5Number of patient INR lab measurements Stat Narcan Administered Outside of ED per the Number of Opioids Administered Outside of ED Number of patients in the denominator population treated with opioids who received naloxone (Narcan) Number of patients who received an opioid agent – exclude ED patients and opioid use for nausea or pruritus Outcome NumeratorDenominator Adverse Drug Event Rate per 1,000 Patient Days Number of adverse drug events in the denominator populationNumber of patient days for Acute Care, Skilled Nursing and Swing Bed patients AHRQ Statistical Brief #109 - Drug Complication per Inpatient Discharge Number of adverse drug events that cause harm in the denominator populationNumber of Acute Care discharges

11. Falls FALLS & IMMOBILITY Process NumeratorDenominator Inpatients Assessed for Fall Risk on Admission per the Number of patient Admissions Number of patients in the denominator population that are assessed for fall risk on admissionNumber of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patients Outcome NumeratorDenominator Falls Resulting in No Apparent Injury Rate per Patient Day* Number of patients in the denominator population that have unplanned descent to the floor resulting in no visible sign of injury, stable vital signs and patient denial or pain or discomfort Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients Fall Resulting in Minor Injury Rate per Patient Day* Number of patients in the denominator population that have unplanned descent to the floor resulting in minor cuts, minor bleeding, minor skin abrasions, minor swelling and minor contusions or bruising Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients Fall Resulting in Moderate Injury Rate per Patient Day* Number of patients in the denominator population that have unplanned descent to the floor resulting in excessive bleeding, lacerations requiring sutures, temporary loss of consciousness or moderate head trauma Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients Fall Resulting in Major Injury Rate per Patient Day* Number of patients in the denominator population that have unplanned descent to the floor resulting in fracture, subdural hematoma, other major head trauma, cardiac arrest or patient requiring transfer to ICU or OR Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients Fall Resulting in Death Rate per Patient Day* Number of patients in the denominator population that have unplanned descent to the floor resulting in death Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn and respite patients Count of Assisted Falls Number of Acute Care, Skilled Nursing Care, Swing Bed and Observation events where the patient is assisted or eased to the floor. *Do not include patients assisted or eased to the floor Fall Rate Resulting in Fracture or Dislocation Number of patient discharges in the denominator population with non-POA, fall-related ICD-9/ICD-10 code with fracture or dislocation (CMS HAC) Number of Acute Care discharges

12. Pressure Ulcers PRESSURE ULCERS Process NumeratorDenominator At-risk Inpatients Receiving Full Preventative Pressure Ulcer Care per Number of At-risk Inpatients Number of at-risk patients in the denominator population receiving full pressure ulcer preventative care Number of at-risk patients identified for Acute Care, Skilled Nursing Care and Swing Bed patients Outcome NumeratorDenominator Stage III, IV or Unstageable Pressure Ulcer Rate per Patient Day Number of patients in the denominator population with non-POA secondary ICD-9/ICD-10 code(s) for pressure ulcer AND secondary ICD-9/ICD-10 diagnosis code(s) for Stage III, Stage IV or unstageable pressure ulcer (AHRQ PSI 3) Number of discharges for Acute Care, Skilled Nursing and Swing Bed patients Stage II, III, IV or Unstageable Pressure Ulcer Rate per Patient Day Number of patients in the denominator population with non-POA secondary ICD-9/ICD-10 code(s) for pressure ulcer AND secondary ICD-9/ICD-10 diagnosis code(s) for Stage II, III, Stage IV or unstageable pressure ulcer (adapted AHRQ PSI 3) Number of discharges for Acute Care, Skilled Nursing and Swing Bed patients

13. OB Obstetrical Adverse Events Process NumeratorDenominator Compliance Rate for Elective Induction Bundle Number of patients in the denominator population with full elective labor induction bundle compliance Number of patients who have delivered and received oxytocin for elective induction of labor Outcome NumeratorDenominator Patients with Elective Deliveries Between 37-39 weeks per Patients Delivering Newborns From 37 - 39 Weeks Gestation Number of elective maternal deliveries between 37-39 weeks gestation with no medical indication All deliveries between 37-39 weeks gestation

14. OB (cont) Obstetrical Adverse Events (cont) Primary Cesarean Delivery Rate, Uncomplicated Number of maternal inpatients with either MS-DRG code for Cesarean delivery or any-listed ICD-9/ICD-10 procedure code(s) for Cesarean delivery without any-listed ICD-9/ICD-10 procedure code(s) for hysterotomy (AHRQ IQI 33) Number of deliveries Peripartum Hysterectomy Rate in Women With Placenta Previa Number of peripartum hysterectomies in women with placenta previa and/or placenta accreta/percretaNumber of deliveries Peripartum Hysterectomy Rate in Women Without Placenta Previa Number of peripartum hysterectomies in women without placenta previa and/or placenta accreta/percretaNumber of deliveries Birth Trauma Rate - Injury to Newborn Number of Newborns with ICD-9/ICD-10 code(s) for birth trauma (AHRQ PSI 17)Number of Newborns Obstetrical Trauma Rate - Vaginal Delivery With Instrument Number of vaginally-delivering, instrument-assisted Moms with ICD-9/ICD-10 code(s) for 3rd or 4th degree obstetric trauma (AHRQ PSI 18) Number of vaginal deliveries with ICD-9 procedure code(s) for instrument-assisted delivery Obstetrical Trauma Rate - Vaginal Delivery Without Instrument Number of vaginally-delivering, non instrument-assisted Moms with ICD-9/ICD-10 code(s) for 3rd or 4th degree obstetric trauma (AHRQ PSI 19) Number of vaginal deliveries without ICD-9 procedure code(s) for instrument-assisted delivery Obstetrical Trauma Rate - Composite - UNDER DEVELOPMENT Number of maternal inpatients with one or more of the following outcomes:Number of deliveries Extended postpartum length of stay (> 3 days for vaginal delivery/> 5 days for Cesarean delivery) Transfer to ICU Transfer to acute care hospital Stroke Seizure Renal failure/kidney problems Pumonary edema Aspiration pneumonia Placental abruption Any blood transfusion Cardiac arrhythmia Resuscitation Amniotic fluid embolism Deep vein thrombosis

15. VTE VTE (Venous Thromboembolism) Process NumeratorDenominator Percent of Inpatients VTE Appropriate Prophylaxis Number of patients in the denominator population identified as at risk for VTE who received appropriate prophylaxis or have documentation why no VTE prophylaxis was given within 24 hours of hospital admission or surgery end time (CMS VTE 2) Number of patients admitted to Acute Care, Skilled Nursing Care or Swing Bed with stays of >48 hours Outcome NumeratorDenominator Inpatients Who Develop VTE per the Number Inpatient Discharges Number of patients in the denominator population with non-POA secondary ICD-9/ICD-10 code(s) for DVT or PE (AHRQ PSI 12) Number of discharges for Acute Care, Skilled Nursing and Swing Bed patients Rate of Potentially Preventable Venous Thromboembolism Number of patients in the denominator population who received no VTE prophylaxis prior to VTE diagnostic test order date (CMS VTE 6) Number of confirmed VTEs during hospitalization for Acute Care, Skilled Nursing Care and Swing Bed patients

16. Safety Across the Board Patient Safety for Selected Indicators - AHRQ PSI 90 The weighted average of the observed-to-expected ratios for the following component indicators: PSI #3 - Pressure Ulcer Rate PSI #6 - Iatrogenic Pneumothorax Rate PSI #7 - Central Venous Catheter-Related Blood Stream Infection Rate PSI #8 - Postoperative Hip Fracture Rate PSI #9 - Perioperative Hemorrhage or Hematoma Rate PSI #10 - Postoperative Physiologic and Metabolic Derangement Rate PSI #11 - Postoperative Respiratory Failure Rate PSI #12 - Perioperative Pulmonary Embolus or Deep Vein Thrombosis PSI #13 - Postoperative Sepsis Rate PSI #14 - Postoperative Wound Dehiscence Rate PSI #15 - Accidental Puncture or Laceration Rate Numerator Denominator Death Rate among Surgical Inpatients with Serious Treatable Complications Death rate determined for each of these serious treatable conditions include: Pneumonia, pulmonary embolism or deep vein thrombosis, sepsis, shock or cardiac arrest or gastrointestinal hemorrhage/acute ulcer. (AHRQ PSI 4) Number of deaths for patients in the denominator populationNumber of surgical discharges for inclusion/exclusion criteria: Age 18 - 89 MDC 14 (pregnancy, childbirth and puerperium Selected list of surgical ICD-9 procedures Principal procedure occurring within 2 days of admission or admission type elective AHRQ Never Event Composite - UNDER DEVELOPMENT CMS HAC Rate Composite - UNDER DEVELOPMENT

17. 100 E. Grand Ave., Ste. 360 Des Moines, IA 50309-1800 Office: 515.283.9330 Fax: 515.698.5130 www.ihconline.org Thank You